'-^n^^ 






I LIBRARY OF CONGRESS. I 



$p:^?- 



UNITED STATES OF AMERICA. 




ilauiiriqht ^o. 






'■:?*■ 



THERMIC FEVER, 



OR 



SUNSTROKE. 



BY ^y---,:,. (%^y 



H. C. WOOD, Jr., M.D., ■ 

Professor of Medical Botany, and Clinical Lecturer on Diseases of the Nervous 

System in the University of Pennsylvania ; Physician to the 

Philadelphia Hospital. 



BOYLSTON PRIZE ESSAY. 



PHO BONO PUBLICO. 



PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

1872. 







Entered according to Act of Congress, in the year 1872, by 

J. B. LIPPINCOTT & CO., 
In the Office of the Librarian of Congress at Washington. 



TO 

id:ei. s. -v^eii^ nyniTOKCELXi, 

Not only as a tribute to his high renown as an original investigator, 
and an offering of personal attachment ; but also as a grate- 
ful acknowledgment of practical sympathy and 
generous aid to the author in his early at- 
tempts at medical research, 

THIS BOOK IS RESPECTFULLY 



Icbicafeb, 



PREFACE. 



About ten years ago my attention was directed 
very forcibly to the subject of sunstroke by the 
cases which I witnessed at the Pennsylvania Hos- 
pital, when resident physician. At that time I 
noted the peculiar rigidity of the heart after 
death, about which so much is said in this essay. 
The great interest excited in me by the disease, 
and the fact that my observations were rather de- 
rided in certain quarters, long since determined 
me to make at some time an experimental study 
of the subject. The present essay is the result of 
this determination. 

Although my effort has been awarded the 
Boylston Prize of the Harvard University, yet 
with some hesitation I place it before the med- 
ical public, claiming only that I have endeavored 
simply to find the truth, and asking that any 

(5) 



6 PREFACE, 

shortcomings may be pardoned, because my work 
has been honest in its intentions and desires. 

The following is extracted from the minutes of 
the Boylston Medical Committee : 

** By an order adopted in 1826, the Secretary was directed 
to publish annually the following votes ; 

** 1st. That the Board do not consider themselves as ap- 
proving the doctrines contained in any of the dissertations 
to which premiums may be adjudged. 

" 2d. That in case of publication of a successful disserta- 
tion, the author be considered as bound to print the above 
vote in connection therewith." 



PART I. 

CLINICAL HISTORY. 



Introductory. — There can be no doubt that under 
the name of sunstroke or conp de j<?/^// sudden cases 
of severe illness of very different natures have been 
described by authors. Such of these cases as have 
really been dependent upon exposure to excess- 
ive heat can be classified under two, or perhaps 
three, heads, to which the names of acute meni7t' 
gitis or phreititis^ heat exhaustion^ and thermic fever 
or true sunstroke^ may be respectively applied, as 
more or less expressive of the pathological condi- 
tions existing. 

Acute meningitis or phrenitis, due to exposure 
to the sun and the direct action of its rays i^on 
the head, must be a very rare affection. In fact, I 
have no positive evidence to offer of its existence 
in nature, having never seen or read an unequiv- 
ocal record of such a case, and therefore will pass 
this theoretical class by without further allusion. 

Simple exhaustion, due to excessive labor in a 

(7) 



8 THERMIC FEVER, OR SUNSTROKE. 

heated atmosphere, is an affection so very distinct 
from true sunstroke, that it is strange it should 
ever have been confounded with the latter. It 
does not differ in its pathology or symptoms from 
other forms of acute exhaustion, offering like them, 
as its chief features, a cool, moist skin, and a rapid, 
feeble pulse, associated with great muscular weak- 
ness, and a tendency to syncope. The following 
case is the only one I have seen ; the notes are 
from memory, and therefore not so full as might 
be desired. 

Case. , set. about 50, was brought into my office at 

I P.M. of a hot July day. He appeared to be a man of feeble 
physical organization, and, after rallying, stated that he had 
been feeling exceedingly weak and ill for several days. He 
was in a semi-unconscious, syncopal condition, with an ex- 
ceedingly rapid, fluttering pulse, a cool, damp skin, and 
pale face. I had him laid flat upon his back, and brandy 
administered very freely. Under its use the pulse soon be- 
came much steadier and slower ; half an hour afterwards 
he was able to walk with assistance to a carriage ; and I 
heard of him no more. 

Some years ago the late Prof Wm. Pepper 
(American Journ. Med. Sci., Jan. 185 1) reported 
to the College of Physicians certain cases of sun- 
stroke, in which on post-mortem examination he 
found the heart very much softened and relaxed. 
As he distinctly states that the surface during life 
was cool, there can be but little doubt that his 



CLINICAL HISTORY, g 

cases really belonged to the affection now under 
consideration. 

In the discussion that followed the reading of 
his paper, Dr. Condie described very clearly the 
two classes of sunstroke cases, and was, so far as I 
know,*the first American writer who clearly rec- 
ognized the distinction. He evidently believed 
Dr. Pepper's patients to be suffering simply from 
exhaustion. 

As there is nothing peculiar in these cases, I do 
not think that they should have any especial name. 
The term heat-exhaustion might be applied to them 
had it not been used to signify true sunstroke. The 
main point to be borne in mind is, however, that 
such cases should not be called sunstroke, as they 
have not the slightest affinity with that disorder. 

Causation. — It is the third class of cases, then, to 
which I would restrict the name of sunstroke, and 
which alone offer a disease jr///^^;^mi", as well marked 
and distinctive in its clinical history and anatomical 
lesions as any affection at present known. 

Although this paper has for its chief object the 
discussion of the pathology of sunstroke, yet a 
sketch of the clinical history is an evident neces- 
sity to its completeness. 

In the first place, in regard to the etiology of the 
disease, my own experience is, that the only abso- 



lO THERMIC FEVER, OR SUNSTROKE. 

lutely necessary, and the ever-present, immediate 
cause, is heat, solar or artificial. It was formerly 
believed that exposure of the head to the direct 
rays of the sun was requisite, but this is now well 
known not to be true. One of my own cases origi- 
nated in a sugar refinery. 

Dr. Longmore tells us that out of sixteen cases 
seen by him in one epidemic, thirteen originated 
in barracks or hospital. 

M. Boudin, as quoted by Dr. W. C. Maclean 
(Reynolds's Syst. of Med., vol. ii. p. 157), states that 
one hundred cases of sunstroke occurred on the 
French man-of-war Duquesne, most of them at 
night, when the men were lying in their bunks. 

Dr. Morehead (Researches on Diseases of India, 
vol. ii. p. 583) says that direct exposure to the sun, 
although a frequent, is not a necessary condition 
to the production of the disease. 

Dr. Geddes (Clinical Observations on Diseases of 
India, London, 1846) details a case which occurred 
in the hospital in the person of a man convalescent 
from measles. 

Dr. Barclay says (Madras Quarterly Journal, 
No. 2, i860), ''The attacks of insolation came on, 
with very few exceptions, when the men were in 
the tents, — generally during the day, but in several 
instances during the night, — never, except in one 
instance, along the line of march. The patient 
had generally been lying down, and often seem- 



CLINICAL HISTORY. 



II 



ingly asleep, or, as it would probably be more ac- 
curate to say, attempting to induce sleep. Some- 
times the attention of his comrades was first directed 
to him by his hurried and heavy breathing, and on 
attempting to arouse him he was found insensible." 

Dr. Bonnyman (Edinburgh Med. Journ., vol. xiv. 
p. 1029, 1864) says, **By far the greater number of 
cases that yearly occur in India are of men who 
have not been exposed to the sun. It is not un- 
usual for men to go to bed in apparent health, and 
to be seized during the night; and patients in hos- 
pital, who have been confined to bed for days pre- 
viously, are frequently the subjects of attack." 

Dr. Swift (p. 47) asserts that the same affection 
may be caused by exposure to artificial heat, and 
that eleven of his cases were attacked in the laundry 
of a hotel, and several were brought from sugar re- 
fineries. 

These quotations could be very much increased 
in number, but they are surely sufficient to show 
that exposure to the direct rays of the sun is in no 
degree necessary for the production of coup de soleil. 
The testimony of authors, and that of common 
experience, that sunstroke occurs only in a highly- 
heated atmosphere, are indeed so concordant, that 
it is certainly allowable to take this point for granted 
as long ago proven. 

There has, however, prevailed in certain quarters 
an idea that intemperance, and even malaria, were 



12 THERMIC FEVER, OR SUNSTROKE, 

necessary factors in the production of coup de 
soleil. 

There can be no doubt that in this country a 
large number of the cases occur in the persons of 
habitual drinkers ; but the most temperate are not 
exempt. 

In India, among the European soldiery, the tem- 
perate would seem at times to afford even the 
larger proportion of victims, because the vagabond 
drunkard soldiers are notoriously shirkers of duty. 
Thus, of eight fatal cases in the 71st Highlanders, 
occurring on the 7th of May, 1858, six were sober 
men, one a '' tolerably free liver," and one a '* free 
liver" (Crawford, Madras Quarterly, No. 2, p. 30, 
i860). Dr. Crawford also says (p. 315), "I can 
point to many soldiers whose lives are spent in an 
unvarying round between the canteen, the guard- 
room, and the prison, and yet they do not die of in- 
solation at a time when our best non-commissioned 
officers are victims to the apoplectic form of ardent 
fever." Both he and Dr. Barclay also insist that 
malarial poison is in most instances of insolation 
not present, and does not when existent strongly 
predispose to attacks. 

The real and sole producing cause of the disease 
is, therefore, Heat. There are, however, various pre- 
disposing causes, which greatly aid the exciting 
cause probably by lessening the powers of resist- 
ance to it. First in importance among these is a 



CLINICAL HISTORY, 



13 



want of acclimatization. Foreigners are always at- 
tacked in much larger numbers than natives of the 
tropics. It must be remembered, however, that no 
amount of acclimatization w^ill afford certain pro- 
tection, as even the Hindoo, born and bred in the 
stifling atmosphere of Bengal, is occasionally at- 
tacked. 

A second important predisposing cause is habit- 
ual intemperance, all or almost all authorities co- 
inciding in the assertion that habitual drinkers 
afford a much larger proportion of victims than 
temperate men when the exposure is the same. 

A third predisposing cause is debility, and espe- 
cially that debility or exhaustion which has been 
brought on by fatigue, and in the highest degree 
by fatigue in a heated atmosphere. The most 
frightful epidemics on record have had this pre- 
disposing cause for their ground-work. 

A very marked instance of such an epidemic 
is that recorded by Dr. Barclay (loc. cit.). The 
43d Regiment, to which he was attached, made a 
most extraordinary march of over eleven hundred 
miles, chiefly through the lowlands of India, and 
at the hottest season of the year. This march 
was continuous, with the exception of a few brief 
halts. No cases of sunstroke occurred until nine 
hundred and sixty-nine miles had been traversed, 
and the men had become thoroughly exhausted, 
and even markedly emaciated. Shortly after this 



14 THERMIC FEVER, OR SUNSTROKE. 

the regiment rested some eight days, and then 
started again, arriving soon in a valley in the Bis- 
ramgunge Ghat, a narrow ravine, with precipitous 
walls nearly a mile in height. During the day 
the thermometer in the tents ranged from 115° to 
127°, and on one occasion was noted 105° at mid- 
night The number of cases of insolation now be- 
came very great, and although most of them recov- 
ered, two officers and eleven men were lost in the 
four days during which the regiment remained en- 
camped. Although the air became cooler as the 
regiment emerged from the hills, yet seven more 
fatal cases occurred in three days. The further 
following of Dr. Barclay's account is not necessary 
for our purpose. It certainly shows that exhaus- 
tion from severe labor at a high temperature is a 
powerful predisposing cause of sunstroke. 

Another predisposing cause, according to the 
testimony of Indian observers (especially Dr. Bar- 
clay, p. 378), is a febrile state. Some have deemed 
that malaria was especially active in this respect, 
but, as Dr. Barclay states (loc. cit, p. 378), *'at 
the season when insolation prevails, malaria is 
never present in the air in any quantity." 

Still another predisposing cause appears to be 
crowding in badly-ventilated barracks. Dr. Butler 
says, as quoted by Maclean, '' Assuredly those 
barracks the most crowded, least ventilated, and 
worst provided with punkahs and other appliances 



CLINICAL HISTORY, 



15 



to moderate excessive heat, furnished the greatest 
number of fatal cases." Mr. Longmoresays, "Nearly- 
half the deaths occurred in a single company of the 
regiment quartered in the barrack which was man- 
ifestly the worst conditioned as to ventilation, and, 
indeed, in every sanitary requirement.'* 

A predisposing cause, which in the past has 
added to the mortality list of sunstroke among 
British soldiery, has been improper clothing, 
** The buttoned-up, tight-fitting coats, the leather 
stocks, as stiff and unyielding as horse-collars, the 
heavy cross-belts, so contrived as to interfere with 
every movement of the chest, the heavy felt shakoes 
mounted with brass ornaments, with wide, flat, 
circular tops, ingeniously contrived to concentrate 
the sun's rays upon the top of the head," no doubt 
very seriously interfered with the soldier's power 
of resisting the high temperature. 

In reviewing these various predisposing causes, 
it will be found that all of them either render the 
nervous system more sensitive to the morbific 
agent, — heat, — or else interfere with the glandular 
system, so weakening it that it is unable to afford 
the proper secretions whose evaporation shall 
enable the body to resist the external heat, or 
perhaps act in both of these ways. 

Thus, want of acclimatization means simply an 
unaccustomed condition of the nervous system to 
the stimulant, heat, and also, probably, that the 



1 6 THERMIC FEVER, OR SUNSTROKE. 

glandular system, from want of training, so to speak, 
is unable readily to produce the requisite amount of 
secretion. Again, intemperance causes the same 
results in a slightly different form : organically 
weakened nervous system and organically altered 
glandular apparatus are unable to cope with the 
morbific agent. 

Syrnptovis — Course, — The idea that sunstroke 
attacks its victims instantaneously certainly obtains 
among the people, and to some extent even among 
the profession. 

The truth seems to be, however, that in most in- 
stances the affection gives abundant warning of its 
approach, although in others it attacks very sud- 
denly. The histories of nearly all the cases herein 
reported were very imperfect, yet in one (Case 5) the 
wife of the sufferer gave a very distinct statement 
that the man had had severe headache, vomiting, 
and Aveakness previously to the attack. An exam- 
ination of clinical records shows much more posi- 
tively that prodromes, or symptoms preceding 
unconsciousness, are very common, and, indeed, 
generally present. 

Dr. Morehead, in his work on the Diseases of 
India, clearly recognizes their existence. He says, 
p. 583, ''In this degree there is much headache, 
with intolerance of light, and contracted pupils, 
succeeded by suffused eyes and drowsiness or quiet, 



CLINICAL HISTORY, 1 7 

delirium, or convulsions, — followed by coma with 
dilated pupils." 

Dr. Longmore (London Lancet, March, 1859) 
calls attention to excessive irritability of the blad- 
der as a symptom preceding attacks of sunstroke. 

Dr. Bonnyman (loc. cit.) says, " Where premoni- 
tory symptoms show themselves, they are some- 
times well marked. Those usually observed are, 
— inaptitude and disinclination for any exertion, 
drowsiness, or a desire to sleep, vertigo, headache, 
and slight confusion of ideas ; the patient feels 
weak, sighing frequently; the appetite is gone, 
thirst is increased, and the bowels are constipated ; 
the symptoms become aggravated, and the patient 
either passes into the state of profound coma, 
or symptoms of the first or progressive form of the 
malady are complained of, viz., distressing head- 
ache, with a feeling of weight and heat in the 
occiput, tightness, distention, and throbbing in the 
forehead and temples, anxiety at the praecordia, 
nausea, and a disposition to vomit. A sensation 
of sinking or of insupportable weight, or uneasi- 
ness, is referred to the pit of the stomach, and a 
feeling of horror or of impending calamity, with a 
tendency to weep, is experienced. The breathing 
is natural, or slow and sighing. The face is gen- 
erally natural or somewhat flushed, eyes bright, 
pupils either natural or somewhat contracted. 
The skin is very hot and dry ; the pulse is full and 



1 8 THERMIC FEVER, OR SUNSTROKE, 

accelerated, tongue white, thirst intense, bowels 
confined, the iiriiie suppressed. If these symptoms 
persist, tetanic convulsions suddenly appear, and 
the patient lapses into the second or severe form 
of the disease." 

Dr. J. R. Taylor says ('' On Erethismus Tropi- 
cus," London Lancet, 1858, vol. ii. p. 355), ''The 
symptoms in these cases were, weakness, pains in 
the limbs, great oppression at the prsecordia, and, to 
use the patient's own words, ' a burning pain inside.' 
An indefinite pain in the head was always admitted 
upon inquiry, and sometimes, but not in many in- 
stances, was the most prominent cause of com- 
plaint." 

Dr. Swift states that premonitory symptoms were 
wanting in the majority of his cases, but that the 
insensibility was very generally preceded by pain in 
the head, disordered vision, a sense of weight in 
the epigastrium, and sometimes nausea and vomit- 
ing. Surrounding objects appeared of a uniform 
color, in most cases blue or purple, in some red, 
green, or even white. 

Dr. Staples (British Army Reports, 1868) states 
that as seen by himself prodromes were always 
present, the disease appearing in fact to come on 
gradually, there often seeming to be no line of 
demarkation between the prodromatous stage and 
the stage of complete insensibility, the latter 
coming on gradually. 



CLINICAL HISTORY. 



19 



All the cases of sunstroke which have come 
under my observation have been in the hospital, 
and therefore represent only the severe, fully-formed 
disease. The symptoms have been very constant. 
Total insensibility was always present, with, in 
rare instances, delirium of the talkative form, and 
still more rarely the capability of being roused by 
shaking or shouting. The breathing was always 
affected, sometimes rapid, sometimes deep and 
labored, often stertorous, and not rarely accompa- 
nied by the rattle of mucus in the trachea. The 
face was often suffused, sometimes, with the whole 
surface, deeply cyanosed. The conjunctiva was 
often injected, the pupils various, sometimes di- 
lated, sometimes nearly normal, sometimes con- 
tracted. The skin was always intensely hot, and 
generally, but not always, dry ; when not dry, it 
was bathed in a profuse perspiration. The intense 
burning heat of the skin, both as felt by the hand 
and measured by the thermometer, was one of the 
most marked features of the cases. The degree of 
heat reached during life was, in my cases, mostly 
io8°-i09° F. The pulse was always exceedingly 
rapid, and early in the disease often not wanting 
in force and volume; later it became irregular, 
intermittent, and thready. The motor nervous 
system was profoundly affected : sitbsiiltus tendi- 
num was a very common symptom, great restless- 
ness was also very often present, and sometimes 



20 THERMIC FEVER, OR SUNSTROKE. 

partial spasms or even violent general convulsions. 
The latter were at times epileptiform, occurring 
spontaneously, or they were tetanoid and excited 
by the slightest irritation. Sometimes the spinal 
cord appeared to be paralyzed, the patient abso- 
lutely not moving. 

Dr. Barclay also notes this difference in cases in 
regard to the motor apparatus. He says (p. 364), 
** In a large proportion of cases, from the commence- 
ment of the attack till its termination in death the 
patient never moved a limb or even an eyelid. A 
comparatively small number of cases, however, 
were from the first attended with convulsions. 
These generally began in the upper extremities, 
and in some cases they did not extend farther, 
the patient either becoming rapidly insensible 
or recovering ; but in other instances they ex- 
tended to the whole of the voluntary muscles, 
and were of the most violent description, — ceasing 
frequently for from two to three, to fifteen or 
twenty minutes, and recurring again with increased 
severity." 

Petechise and ecchymosis, the evidences of 
broken-down blood, were present in some of my 
cases, and there was, in one or two instances, even 
a fetid hemorrhagic exudation from the nostrils 
during life. A symptom which has pretty much 
escaped the attention of authors was the peculiar 
odor. This was most marked in those patients 



CLINICAL HISTOR V. 2 1 

who had involuntary passages, but was very dis- 
tinct from any fecal odor. The stools emitted it 
very strongly, but so did the skin and breath. It 
was so distinctive as to render possible the recog- 
nition of a case by the sense of smell alone. The 
discharges from the bowels were liquid and very 
often involuntary. None of the cases passed urine 
whilst under observation. 

These symptoms agree very well with the de- 
scriptions of most authors. Dr. Barclay (loc. cit), 
however, says that in his cases ^' the eyes were 
fixed anjd slightly turned upwards, becoming grad- 
ually more and more glassy, as if from the forma- 
tion of a film over the cornea ; the pupils greatly 
contracted ; the conjunctiva pinky, the color grad- 
ually becoming deeper; the congestion at first 
being deep-seated. The face was invariably pale, 
never in any instance bloated or flushed, as has 
been described by others. The heart's action was 
very rapid and sharp, the impulse and the pulsa- 
tions in the carotid being perceptible to the eye 
from a considerable distance." 

The truth seems to be that all the minor symp- 
toms vary, — that the important characteristic and 
always-present symptoms of this variety oi coup de 
soleil may be summed up as intense fever with 
profound disturbance both of the cephalic and 
spinous nervous system ; the disturbance manifest- 
ing itself in the form of insensibility, with or with- 



22 THERMIC FEVER, OR SUNSTROKE. 

out delirium, and with restlessness, convulsions, or 
paralysis of the motor tract. 

The following notes of cases were all taken 
during my residency in Pennsylvania Hospital, 
and, having been made before I was conversant 
with the literature of the subject, or had thought 
much about it, are unfortunately not so full on 
certain points as is desirable: 

Case I. — T. B., Irishman, aet. about 30, was brought 
into the ward at i P.M. August 2, 1863. He was said to 
have fallen whilst walking in the street a few minutes 
before. He was perfectly unconscious, with very labored 
breathing. His pupils were not markedly dilated or con- 
tracted, and yielded sluggishly to light. His skin was 
cyanosed and very hot and dry. He had vomited and 
passed his feces unconsciously. His pulse was no, quick 
and moderately strong. He could scarcely swallow. Tur- 
pentine injections and brandy were exhibited; but the man 
died at 5 p.m. 

Autopsy, two hours after death, — Rigor mortis marked. 
Venous trunks of the meninges of the brain loaded with 
dark blood. Brain substance normal. Lungs congested. 
Heart rigidly contracted. A thermometer in thorax indi- 
cated 108° F. Blood very dark-colored, with a slightly acid 
reaction ; not coagulating. Blood-corpuscles under the 
microscope normal, but very dark-colored. 

Case II. — Irishman, set. 64, a moderately stout, muscular 
man, was brought into the ward about 7 p.m. August 10. 
His skin was very hot, belly tympanitic, pulse 177, not 
intermittent, but very weak. He had had involuntary dis- 
charges from the bowels. The face was very much con- 



CLINICAL HISTORY. 23 

torted by spasms, repeated pretty regularly 130 times a 
minute. He was treated with turpentine injections, brandy, 
aromatic spirits of ammonia, etc. He died quietly at 1 1 J p.m. 
Autopsy, one hour after death. — Venous trunks of the me- 
ninges of the brain loaded with blood. Brain substance nor- 
mal, not congested. No bloody or serous effusion. Heart 
rigidly contracted. Kidneys normal. Blood very dark and 
fluid ; of a slightly acid reaction. 

Case III. — German. A discharged soldier; very intem- 
perate ; a large, fat man, weighing about 200 pounds. He 
was brought into the wards at i p.m. August 10. Those who 
brought him in stated that he had fallen suddenly whilst 
loading a dray, about an hour and a half previously. His 
skin was^ of a dark-reddish color, the capillaries refilling 
very slowly when they were emptied by pressure with 
the finger, it requiring several seconds for them to do so. 
His pulse was 170 and upwards, very irregular and intermit- 
tent, but not excessively weak or thready. He was perfectly 
unconscious, but lay absolutely still, without even subsultus 
tendinum. His pupils were contracted. The conjunctiva not 
sensitive, and very much congested. His skin exemplified 
calor mordax. A thermometer placed in the axilla indi- 
cated 109° F. His breathing was slow, very labored, and 
irregular. He had involuntary discharge of feces. He 
gradually grew worse, and before death bloody, dirty foam 
trickled from the nose and mouth. Death occurred at 2J p.m. 

Treatment. — Frictions with ice ; brandy and ammonia, as 
much as could be forced down him. Turpentine injections. 

Autopsy, one hour after death. — Cadaver intensely hot, 
very fat, no rigor mortis. Meningeal venous trunks en- 
gorged. Brain substance normal. Left heart slightly con- 
centrically hypertrophied, very firmly contracted. Kid- 
neys normal. Blood very dark-colored, fluid, coagulating 
slightly, forming not more than a grumous mass. 



24 



THERMIC FEVER, OR SUNSTROKE. 



Case IV. — C. H., Englishman, over 60 years of age, was 
brought to the hospital at \\ p.m. August 11. He was said 
to have fallen in the street one or two hours previously. He 
was very restless, almost convulsive ; breathing labored 
and noisy; pulse 170, and slightly intermittent; skin burn- 
ing hot ; temperature in axilla 109° F. His pupils were con- 
tracted, the conjunctiva dry, non-sensitive, and injected. 
There was some, but not strongly pronounced, stasis in the 
capillaries of the skin. 

Treatment. — Brandy, aromatic spirits of ammonia, tur- 
pentine injections, and rubbing with ice. He died in half 
an hour. 

Autopsy, one hour after death. — Cadaver very fat. Menin- 
geal venous trunks engorged. Brain substance very slightly 
congested, the ventricles distended, with slightly reddish 
serum ; no effusion of blood. Left heart slightly hyper- 
trophied, firmly contracted. Liver very fatty. Kidneys 
normal. Spleen very much enlarged, and softened. Blad- 
der empty, rigidly contracted. Blood very dark ; coagu- 
lating, but not firmly. 

Case V. — ^J. B. An intemperate Irishman, aet. about 33, 
was brought into the wards of the hospital at 3-j p.m., Au- 
gust 14. His wife stated that on the loth he had been so 
exhausted by the heat, so sick at the stomach, and had 
suffered so much from headache, as to be forced to give up 
work until the morning of the 14th. When he entered the 
ward the skin was very moist, but intensely hot, and cov- 
ered with a rubeoloid eruption. A thermometer placed be- 
tween the thighs indicated 104° F. The pupils were slightly 
contracted, the conjunctiva injected and very sensitive. 
There had been no discharges. The pulse was 140, and 
rather feeble. He was entirely unconscious, but was con- 
tinually muttering unintelligibly, and was very restless. He 
vomited freely. 



CLINICAL HISTORY. 



25 



Treatment. — Cold water poured by the bucketful over the 
head and breast, and turpentine injections. At 4 o'clock 
his restlessness was replaced by convulsions, with very 
marked opisthotonos. These convulsions lasted some five 
or six minutes each, and were somewhat epileptiform ; but 
as the secretion of saliva was entirely dried up, he did not 
foam at the mouth, although his jaws worked violently. 
His breathing was for the most part very hurried, shallow, 
and irregular, but at times labored and slow. He passed a 
few drops of urine, and his bowels were moved by an in- 
jection. Brandy was put in his mouth, but its exhibition 
produced immediately fearful convulsions, probably owing 
to the difficulty of deglutition. 

The cold affusions lowered the temperature of the skin, 
but did not resuscitate him in the least. At 47 o'clock the 
douche was repeated, but this time produced violent spasms, 
with vomiting and great congestion of the face. From this 
time his symptoms deepened, his body became very d.irk- 
blue or purphsh, and he died quietly at 5.15 p.m. No post- 
mortem was allowed. 

Case VI. — An Irishman, middle-aged, robust, and muscu- 
lar, but not fat, was brought into the wards at 8 p.m., Au- 
gust 14. He was said to have fallen about 3 p.m. He was 
perfectly unconscious, somewhat restless, with muscular 
twitchings and subsultus tendinum. His tongue was very 
dry ; his skin dry, harsh, and hot. The temperature in 
the axilla was 104° F. His pupils were slightly dilated, his 
conjunctiva injected ; pulse 150, weak, not intermittent, but 
somewhat fluttering ; breathing 48 per minute, and very 
laborious. He could swallow only with difficulty. He 
was treated simply with brandy, and died quietly about 
11.30 P.M. 

Autopsy, one hour after death, — No rigor mortis. Tem- 
perature in abdomen 108° F. Brain, with its large venous 

3 



26 THERMIC FEVER, OR SUNSTROKE. 

trunks, engorged, and ventricles containing an abnormal 
amount of serum. Left heart rigidly contracted. Liver 
very fatty. Blood very dark and fluid, with a decided acid 
reaction. 

Case VII. — C. B., German, a large, muscular man, was 
brought into the hospital at 12.30 p.m., August 15. The 
skin was very hot and dry, axillary temperature 109° F. ; 
pupils almost normal, conjunctiva injected, mouth moist, 
deglutition almost impossible. He had a severe convulsion 
immediately after his entrance, and died in a very few min- 
utes. There was a large ecchymosis in one axilla. He was 
said to have fallen whilst working in a sugar refinery, and 
to have been brought at once to the hospital. 

Autopsy, two hours after death, — Meningeal veins gorged 
with blood. Some serous exudation in ventricles. Left 
heart rigidly contracted. Temperature in abdomen i io|° F. 
Blood decidedly acid, very fluid, without a sign of coagu- 
lation. Under the microscope the red corpuscles were ap- 
parently darker than normal. 

Case VIII. — An Irishman, only a few days in the country. 
He was said to have fallen during the latter part of the after- 
noon, whilst wheeling coal. When brought in at 9 p.m. he 
was semi-unconscious, but could scarcely speak intelligibly ; 
his pulse was 90 per minute, moderately strong ; surface dry, 
but not inordinately hot ; he had no pain, but complained of 
great weakness ; he had not had involuntary discharges. 

Treatment. — Ten grs. of muriate of ammonia and f § ss of 
brandy were given every half-hour, and an injection of an 
ounce of turpentine was administered. At 10.30 p.m. his pulse 
had fallen to 80, and his general condition much improved. 
His medicine was directed to be given every hour only. 

August 12, he was entirely conscious, but very drowsy, 
and slept a great deal. 



CLINICAL HISTORY, 2/ 

August 14, well. He now states that previously to his 
attack he had been drinking freely of ice-water, but had not 
been sweating at all, and that he had no premonitory symp- 
toms, no signs of exhaustion, no optical derangement, no 
headache, etc. 

In many of the cases which have come under 
the notice of the author of this memoir, the evi- 
dences of asphyxia were quite marked some time 
before death; but at the same time there was gen- 
erally a consentaneous failure of the heart's action, 
so that the immediate cause of death was not merely 
failure of respiration, but also of the heart's action. 

These cases, I think, represent the ordinary va- 
riety of the disease seen in our large cities. 

According to Maclean, Dr. Morehead* has di- 
vided insolation into three varieties : the cardiac, 
the cerebro-spinal, and the mixed. " In the cardiac 
variety, although it is probable that the sufferer is 
himself conscious of some premonitory symptoms, 
there is seldom time for their full development, so 
as to attract the attention of bystanders, before the 
patient falls, gasps, and, in some severe cases, expires 

* Dr. Maclean gives no reference, and I have not been able to 
find where the classification is made. As the Royal Society's 
catalogue does not ascribe to Dr. Morehead the authorship of any 
especial paper on sunstroke, it seems probable the classification 
was proposed in his work on the Diseases of India. If so, it must 
be in a later edition, for the first contains no reference to any 
such division. 



28 THERMIC FEVER, OR SUNSTROKE, 

before there is time to do much or anything for 
his recovery, death taking place by syncope." 

This variety I have never seen an instance of, 
and further discussion of it will be postponed to a 
later part of this paper. 

The distinction between cerebro-spinal and mixed 
cases is certainly not so evident as the separateness 
of the cardiac variety. If the pathology hereafter 
developed be, as it seems, true, there can be no 
mixture between the cerebro-spinal and the car- 
diac. Leaving out of view the cardiac, it is true 
that cases of insolation may be divided into those 
in which death takes place purely through paraly- 
sis of respiration, and those in which the heart also 
suffers a gradual weakening; but as these cases 
are not practically — i.e. therapeutically — distinct, I 
cannot see any advantage to be gained by such a 
separation, especially as cases in which the heart 
does not suffer more or less are so very rare, that 
I have not only never seen a case, but do not know 
of an unequivocal account of more than one or two. 
The nearest approach to such that I can call to 
mind is the following by Dr. Crawford (Madras 
Journ., No. 2) : 

Case IX. — A. B., aged 24, a soldier, was heard at mid- 
night moving, and his comrades, thinking the noise strange, 
cried out, and, not receiving a reply, got up, and found him 
muttering incoherently about a drink. He became quiet, 
then comatose, and when I [Dr. Crawford] saw him about 



CLINICAL HISTORY. 20 

a quarter-past one o'clock, I found him moribund ; respira- 
tions short, quick, and stertorous ; pulse full and bounding; 
face flushed, eyes suffused, pupils contracted to a point, and 
skin hot. I had scarcely completed my examination, when 
all the sphincters relaxed ; the contents of his stomach, 
chiefly water, welled from his throat; a frothy mucus 
tinged with blood ran from his nostrils ; his pupils dilated 
to their utmost extent ; a slight tremor crept over his frame, 
and he was dead. 

In contrast with this, as representing a typical 
** mixed" case, may be cited the following from 
Dr. Barclay's paper (loc. cit, p. 368) : 

Case X. — R. C, set. 26 ; not intemperate ; was attacked 
with fever, while on guard, on the 26th of May, and came 
into the hospital the evening of the same day. On the 
morning of the 27th he was quite free from fever, but 
rather weak, and was detained in consequence. He lay on 
his cot during the forenoon without making any complaint. 
About noon was observed to be in a state of insensibility, 
and breathing heavily. He was removed at once to the 
coolest veranda in the hospital, the cold douche applied 
over his head, chest, and back, and eight leeches applied to 
his temple by the apothecary then on duty. 

At 1.2 P.M. I saw him. He was then completely insensible, 
his face paler than usual, his eyes fixed and slightly turned 
upwards, the pupils somewhat contracted, but much less so 
than was usual in the cases in the field. His skin felt burn- 
ing to the touch. His pulse was frequent and rather full. 
The pulsation in the carotid was very strong, and could be 
seen at a distance. He had no convulsions, nor could the 
slightest movements of his limbs or eyelids be observed 
for hours. On stethoscopic examination, loud subcrepitant 
rales were heard all over the chest. The first sound of the 

3* 



30 THERMIC FEVER, OR SUNSTROKE. 

heart was natural, the second indistinct. The leeches, which 
had drawn very little blood, were removed, and there was 
scarcely any bleeding from the bites. The cold douche was 
applied assiduously for some time, but without any good 
result, and had to be discontinued on account of failure of 
the pulse. An attempt was made to give a stimulant, but 
nothing could be swallowed. A purgative enema was given 
at once, and a considerable quantity of thin feculence was 
brought away with it. Enemata of brandy-and-water, with 
from fifteen to twenty minims of chloroform, were given re- 
peatedly, but they were never retained for more than a few 
minutes, and no effect seemed to be produced by them. A 
blister was applied to the nape of the neck, sinapisms to the 
chest and feet, and ammonia to the nostrils. His head and 
the whole surface of the body were kept wet, and his face 
assiduously fanned. During the afternoon he became gradu- 
ally worse. His pulse became imperceptible, his conjunc- 
tiva pinky, his hands and feet livid. His head continued 
for a couple of hours firmly bent backwards, and his hands, 
forearms, and toes flexed. By evening the blister had risen 
well, and he then improved considerably. The spasm dis- 
appeared, the lividity of his hands became less, his pulse 
returned, and he regained a certain amount of conscious- 
ness, and was able to swallow with difficulty. A small 
quantity of brandy-and-water was then given every half- 
hour ; and, the bronchial tubes being evidently loaded 
with mucus, he was occasionally turned over on his face, 
his head projecting over the edge of the cot. This change 
of position was generally followed by efforts to vomit, by 
which his breathing was greatly relieved. About midnight 
he began to sink again. The insensibility became more 
profound, and the breathing more stertorous and oppressed. 
A blister was applied to the vertex without any relief. The 
pulse gradually failed, and he died at 3.20 a.m. on the 28th. 



CLINICAL HISTORY, 



31 



Whether the division into mixed and cerebro- 
spinal insolation be accepted or not, I think it must 
be allowed that, in the majority of cases of the dis- 
ease, death is induced by asphyxia, especially when 
it comes on quickly but not instantaneously. The 
general concurrence of authors in this is indicated 
by the frequent use of the name '' heat'' or '' solar 
asphyxia." To corroborate my own observation 
further, I will make one or two quotations. 

Dr. Dowler, of New Orleans, who has watched 
a very large number of cases from immediately 
after the fall until death, says (New York ^Medical 
Gazette, 1842, pp. 214, 215), '' The cause of death 
begins, continues, and ends in the breathing appa- 
ratus. . . . After the death of the lungs or the 
cessation of the respiration, the heart and arteries 
will, in some instances, continue to act." 

Dr. Pirrie says (London Lancet, May, 1859), 
'* The symptoms are distinctly those of that mode 
of dying in which the disease commences at the 
lungs." Dr. Crawford (loc. cit.) goes further, be- 
lieving even the coma to be secondary upon the 
asphyxia. 

The conclusion seems logically inevitable that, 
even in very many rapidly fatal cases, death occurs 
from paralysis of the respiratory centres by the 
excessive heat or other causes. 

There is an affection which is rarely, if ever, seen 
in this country, but which appears to be very com- 



32 THERMIC FEVER, OR SUNSTROKE, 

mon in India, where it is known as arderit continued 
fever. This disease is really scarcely worthy of 
a distinct place in the nosological catalogue, but 
is a variety, or rather degree, of insolation, arising 
from the same cause, presenting a similar but 
less violent array of symptoms, and often passing 
into the fully-formed coup de soleil. One of the 
earliest, and at the same time clearest, accounts of 
this fever which I have met with is that in More- 
head's work on the Diseases of India. After 
stating that, although mental excitement, intem- 
perance, etc. are often factors of importance in the 
production of the disease, elevated temperature is 
the necessary condition, Dr. Morehead gives the 
following account of the symptoms: 

" The attack is generally sudden, often without 
much chilliness. The face becomes flushed ; there 
is giddiness and much headache, intolerance of 
b'ght and sound. The heat of skin is great; the 
pulse frequent, full, and firm. There is pain of 
limbs and of loins. The respiration is anxious. 
There is a sense of oppression at the epigastrium, 
with nausea and frequent vomiting of bilious 
matters. The bowels are sometimes confined ; at 
others, vitiated discharges take place. The tongue 
is white, often with florid edges. The urine is 
scanty and high-colored. If the excitement con- 
tinues unabated, the headache increases, and is 
often accompanied with delirium. If symptoms 



CLINICAL HISTORY. 33 

such as these persist for from forty-eight to sixty 
hours, then the febrile phenomena may subside, the 
skin may become cold, and there will be risk of 
death from exhaustion and sudden collapse. In 
most cases the cerebral disturbance is greater in 
degree, and in these death may take place at an 
earlier period in the way of coma." 

Whether Dr. Morehead has confounded two or 
more fevers somewhat, I do not know ; but Sir J. 
R. Martin certainly says (The Influence of Tropi- 
cal Climates on European Constitutions, p. 208), 
'*We have not here the tendency to collapse 
so characteristic of the true Bengal remittent 
fever." 

A reference to the quotation from the paper of 
Dr. Bonnyman, already given, will show that he 
has evidently seen cases of fever, excited by heat, 
some ending, others not ending, in insolation. 

Dr. Barclay (loc. cit., pp. 365, 367, 368) states 
very plainly that during the hot season of 1858 
there were very many cases of men whose systems 
were in a state of feverish excitement from the heat, 
others which were more serious and were entered 
upon the hospital roll as cases o{ febris contiintus 
communis, and others which were marked as inso- 
lation. 

The line which he drew between the last two 
affections he asserts to have been a purely arbitrary 
one. Those cases in which insensibility or con- 



34 THERMIC FEVER, OR SUNSTROKE, 

vulsions were present, were called insolation ; 
others, common continued fever. 

This evidence might be increased by further 
quotations, but is certainly sufficient to show that 
very often insolation is preceded by an acute 
ephemeral fever, and that this fever is caused by 
exposure to heat, and may exist either with or 
without inducing the symptoms ordinarily known 
as sunstroke : the difference between the affections 
is therefore simply one of degree, not of kind. 

Pathology, — The post-mortem appearances, after 
sunstroke, are mostly negative : there is scarcely 
any constant lesion whatever of the solids, nor is 
congestion of the brain, or serous or haemic effu- 
sion into its ventricles or substance, of frequent 
occurrence. All authors appear to agree in stating 
that the right heart and the pulmonary arteries, 
with their branches, are gorged with dark fluid 
blood. In my cases the lungs did not present at 
all the appearance of congestion of their minute 
capillaries, but when they were cut the blood 
poured from them abundantly, seemingly from 
their larger vessels. Not only do the lungs suffer 
from venous congestion, but the whole body also. 
The blood appears to leave, as it were, the arterial 
system, and collect in the venous trunks. The 
arterial coats are often stained red, apparently from 
the altered haematin of the blood. 



CLINICAL HISTORY, 



35 



In my autopsies I was astonished to find the 
heart, especially the left ventricle, rigidly con- 
tracted. It had been previously stated by some 
observers that the heart was soft and flaccid, whilst 
most had not reported at all the condition of the 
viscus. There was no room for doubt in the ob- 
servation ; in every case the heart was rigid and 
hard to a degree which none of us had previously 
seen. The question at once arose, How is this to 
be reconciled with testimony? The observations 
of Dr. Pepper have already been shown not to be 
applicable to the subject. But there remain those 
of Levick, who failed to find any rigidity. The 
cause of this failure is, however, sufficiently obvi- 
ous. The post-mortems were made from thirteen 
(Levick, Pennsyl. Hosp. Reports, 1868) to thirty 
hours after death. As the temperature of the body 
remains above 100° for hours, it is evident that 
putrefactive changes, often already entered upon 
before demise, must go on very rapidly, and that 
probably even three or four hours would afford 
sufficient time for the relaxation of commencing 
decomposition to follow the heat rigidity. More- 
over, direct evidence of the truth of this is not 
wanting. It has been experimentally demonstrated 
(see Boston Journal of Med., vol. x. p. 350) that in 
animals rigidity of the heart is found directly after 
death from excessive heat, but that in a very few 
hours it disappears. 



36 THERMIC FEVER, OR SUNSTROKE. 

There can be no doubt that the blood suffers 
in sunstroke very similarly to what it does in low 
fevers. Its coagulability is always, so far as my 
experience goes, impaired, but not always de- 
stroyed ; and it is probable that in the very rapid 
cases it may not be decidedly affected. Generally, 
the blood appears after death as a dark, often thin, 
sometimes grumous fluid, whose reaction is very 
feebly alkaline, and in some of the cases herein 
reported was even decidedly acid. Dr. Levick (loc. 
cit., p. 373) appears to assert that the blood disks, 
as seen by the microscope, were shriveled and 
crenated, and showed very slight tendency to ad- 
here in rouleaux. In several of my cases the blood 
was carefully examined by the microscope, but 
nothing abnormal was found. 



PART II. 

NATURE. 



Sufficient of authority and reason has been 
brought forward to make it at least probable that 
heat is the sole exciting cause of sunstroke. This 
being so, it is to be expected that the lower animals, 
as well as man, should suffer from the affection, 
and experience fully corroborates this a priori 
reasoning. We are able, therefore, to induce sun- 
stroke in animals, and, by varying its conditions, 
study its nature much more thoroughly than can 
be done at the human bedside. A discussion of 
the nature of coup de soleil must, I conceive, rest 
largely upon such basis of experimentation. 

Of the various experimenters upon the effect of 
heat upon animals, I have had access to, and have 
used especially, the w^orks of Dr. Vallin, Dr. Stiles, 
and Claude Bernard. The observations of these 
gentlemen, in so far as they cover the same ground, 
are in close agreement ; and I myself have attained 
similar exp^rirnental results, although I have gone 

4 (37) 



38 



THERMIC FEVER, OR SUNSTROKE, 



further and have read the phenomena somewhat 
differently. 

The symptoms produced by exposing an animal 
to excessive heat do not appear to differ save in 
degree, whether the heat be artificial or due to the 
direct rays of the sun, or whether it be moist or 
dry. The animal is at first excited, trying to get 
away from the cage in which it is confined. This 
period of excitement sooner or later, according to 
the intensity of the heat, gives place generally to 
a second stage of profound muscular prostration 
and quietude. From the beginning the respiration 
has been exceedingly hurried, and now very often 
it cannot be counted. The beat of the heart keeps 
pace with the respiration, and panting and ex- 
hausted the animal lies quiet, with the saliva pour- 
ing from its open mouth. This second stage soon 
yields to that of com^a. In my own experiments 
the insensibihty has generally come on gradually, 
not suddenly, and has not been accompanied by 
convulsions. In one case, however, the animal 
was attacked by coma and fatal convulsions with 
absolute abruptness. 

According to Dr. Vallin's experience, convul- 
sions are very commonly present. 

Claude Bernard recognizes them as sometimes 
present, sometimes absent ; whilst Dr. Stiles sa3^s 
that occasionally life is terminated by a fit of con- 
vulsions, but generally it ceases gradually. 



NATURE, 3g 

The resemblance between these symptoms and 
those of coup de soleil of man is very marked. 
There is in many cases of the latter the same 
stage of feverish excitement, the same condition 
of weakness, the same gradually approaching coma . 
In other cases in man the nervous symptoms come 
on suddenly, as they do sometimes in animals. The 
chief difference appears to be, that whilst in animals 
sudden onset of the nervous symptoms is rare, in 
man it is common, the reason evidently being that 
the cephalic nervous system of man is much more 
delicate and more easily disturbed than that of 
animals. The post-mortem appearances are very 
similar to those seen in man. The arterial sys- 
tem is comparatively empty, and there is abso- 
lute engorgement of the large venous trunks 
with blood, whose crasis is more or less broken 
down. 

The muscular system offers the most obvious 
lesion, and it is to this I shall first direct attention. 
Dr. Stiles says (1864), " When the thorax is opened 
(just after death) the ventricles of the heart are 
found rigidly contracted, or become so in five or 
ten minutes, both auricles distended with blood, 
and manifesting fibrillar movements. The cut sur- 
face of the ventricles is acid to litmus-paper; under 
the microscope the muscular fibres of the heart 
have lost their transverse striae." 

Dr. Vallin says (1870), '' At the moment of death 



40 THERMIC FEVER, OR SUNSTROKE, 

the ventricles are contracted upon themselves, glob- 
ular ; the left ventricle in especial has a ligneous 
hardness. Its cavity is effaced, and does not con- 
tain a trace of liquid blood, nor of clot. The auri- 
cles — the right especially, and sometimes the right 
ventricle — are full of black liquid blood, or con- 
fluent clots. The ventricles instantly after death 
are insensible to every kind of stimulus. The au- 
ricles have for a very few minutes spontaneous 
rhythmic movements, but in a little while these 
cease, and cannot be reprovoked; all the muscu- 
lar tissue is strongly acid." 

Claude Bernard says (i 871), "In opening the 
cadaver immediately after death there is found 
generally an arrest of the beating of the heart, a 
black coloration of the blood in the arteries, some- 
times ecchymosis under the skin, and lastly cada- 
veric rigidity comes on with great rapidity" (loc. 
cit, p. 1 39). Claude Bernard and Vallin, then, agree 
in stating that the voluntary muscles are affected 
similarly to the heart, and that the muscles directly 
after death either do not react at all to the stim- 
ulus of galvanism, or do so very feebly and imper- 
fectly, and that post-mortem rigidity comes on 
almost immediately after death. Vallin says, " The 
diaphragm is, after the heart, the muscle which 
loses its irritability most quickly : generally at 
the moment of death it fails to contract under any 
stimulus. Certain muscles of the trunk commence 



NATURE, 41 

to become rigid even during the agony, and in 
about half an hour this rigidity is generally com- 
plete for the whole body. A constant accompani- 
ment of the muscular rigidity is an acid reaction." 
There can be no doubt that in some instances 
this rigidity is almost consentaneous with death. 
Dr. Stiles, however, states that in his experiments 
on rabbits post-mortem rigidity did not come on 
until between one and two hours after death. 

As a study of the subject, the following experi- 
ments were performed. The first two of them were 
made in the last week of September, when the sun 
had already waned in power, without the aid of 
artificial heat. A box was constructed rudely with 
a slanting glass lid, like a miniature green-house. 
It was simply placed upon a brick pavement, when 
used, in such a way that the sun could exert its 
fullest power upon it. 

Experiment i. — Exposed a two-thirds-grown rabbit in a 
box covered with glass. 

I P.M. — Temperature in rectum, 104^°. Temperature of 
box, 120° (F.). 

I.I 5 P.M. — Temperature, io6J°. Respiration very hurried. 

1.30 P.M. — Temperature, 109^°. Has convulsive attacks, 
in which he jumps, and kicks with hind legs with great 
fury. 

1.45 P.M. — Temperature, 112°. Seems very weak and re- 
laxed; breathing 220 a minute. Lies on side, with every 
now and then the attacks alluded to ; slobbering greatly. 



42 THERMIC FEVER, OR SUNSTROKE. 

2.IOP.M. — Temperature of box, 120°. Rabbit on side, 
exceedingly weak, gasping; squealing faintly at intervals. 

2.15 P.M. — Temperature, 114^°. Perfectly unconscious; 
lies relaxed and motionless on the cool ground in the shade. 

2.20 P.M. — Only gasping at long intervals ; heart still 
beating, although laboredly, and somewhat irregularly, yet 
pretty steadily, and with some force. 

2.21 P.M. — Dead. 

Autopsy. — Heart : right side and left auricle full of blood; 
left side, containing blood, not contracted. The heart made 
a few very imperfect and feeble attempts at beating when 
it was cut across. Blood coagulating with great rapidity 
and firmness ; alkaline. Brain not congested. Muscles 
all failing to show the slightest sign of contraction under 
the strongest faradaic current, except some of the leg mus- 
cles, which contracted very feebly, and only at all when the 
current was very intense. 

Experiment 2. — Two-thirds-grown rabbit. Put in a box 
at 1 1.30 A.M. Temperature, 104^°. 

12 M. — Temperature, 109°. Temperature of box, 112°. 

12.25 P-M. — Temperature, iio}°. Rabbit weak, slobber- 
ing a great deal ; breathing with great rapidity. 

I.I 5 P.M. — Rabbit conscious, lying quietly on his side; 
not slobbering ; breathing not nearly so rapid, but deep and 
labored. Temperature, iii^^^. 

1.35 P.M. — Rabbit found dead. Temperature, 112°. 

Autopsy. — Heart : left ventricle empty, very firmly con- 
tracted, with a very evident white spot at apex. Galvanic 
(induced) current very strong, giving rise to no muscular 
movements whatever, either of heart or voluntary muscles. 
Blood coagulating slowly and imperfectly ; reaction neutral, 
or at least so feebly alkaline as to be uncertainly so. Mus- 
cular reaction very decidedly acid. Spinal cord not con- 
gested. Right side of heart gorged with blood. 



NATURE. 43 

Experiment 3. — A large adult rabbit. 

12. 1 1 P.M.— Anal temperature, 105°. Just put in box, 
whose temperature is 130°, heated by very hot brick flues, 
on which the rabbit lies. 

12.15 P.M. — Rectal temperature, 107°. Breathing excess- 
ively hurried. 

12.17 P.M. — Rectal temperature, 109°. 

12.21 P.M.— Rectal temperature, 111°. Had a moment 
since what was apparently a convulsion, and has had nu- 
merous convulsive twitchings since. Appears semi-uncon- 
scious. 

12.25 P-M- — Dead. Temperature in abdomen after death, 
111°. Respiration ceased some time before heart. The tho- 
rax was opened, and the heart was felt with the finger to be 
pulsating. It was then further opened, and the heart was 
seen to be very distinctly pulsating, and gradually becoming 
filled with dark blood. It was punctured, and blood allowed 
to escape ; it made one or two pulsations, and then at once 
became rigid. After this the diaphragm was tried with the 
galvanic current, and responded to it. The muscles of the 
hinder extremity failed to do so, those of the fore legs did. 
Peristaltic action of the intestines was moderately active 
when the body was opened, and on galvanic excitation be- 
came very active. 

Experiment 4. — A moderate-sized dog. 

I P.M. — Put in the hot box. 

I.I 5 P.M. — Anal temperature, 106°. 

1.30 P.M. — Anal temperature, 110°. 

1.40 P.M. — Anal temperature, iio|°. Just dead. 

Autopsy. — As soon as respiration ceased, the body was 
opened. Heart still beating, gorged with dark blood. 
Veins full of dark blood. Blood on being shaken in test- 
tubes rapidly clotting, and slowly changing its color to an 



44 



THERMIC FEVER, OR SUNSTROKE. 



arterial hue. The vessels \vtre carefully examined : no 
clots were found in them. 

Experiment 5. — An adult pigeon. 

1 1 40 A.M. — Rectal temperature, 109°. Just put in box; 
the temperature in box, 130"^; besides, the pigeon was in 
direct contact with the very hot brick flue. 

11.45 A.M. — Respirations very weak. 

12 M. — Has been unable to stand for some time ; has been 
semi-unconscious. Just had a convulsion, followed by per- 
sistent opisthotonos. 

* 12.2 P.M. — Anal temperature, 120°?. (My thermometer 
did not mark higher than 120^, to which the mercury rose; 
the hand could hardly bear the heat of the flesh.) Dead. 
Respiration certainly ceased before the heart's action. 
Rigidity came on almost before heart ceased beating. 
Thorax opened as soon as heart ceased action. The 
heart was found rigidly contracted like a board. Muscles 
acid. 

Experiment 6. — Precisely like last in conditions and re- 
sults. Death temperature the same. 

Experiment 7. — Precisely like last in all respects. Death 
temperature the same. 

In none of these experiments was the thorax 
opened before the heart ceased to beat. 

Experiment 8. — A young pigeon, put in box at 130°, and 
taken out some time afterwards dying. 

The heart being felt to be beating after respirations had 
ceased, the body was opened and the pulsations were watched 
for some time. 



NATURE. 



45 



Experiment 9. 

12.36 P.M. — ^Anal temperature, iio|°. Pigeon put in hot 
box. 

I P.M. — Anal temperature, 113!°. 

1.30 P.M. — Pigeon found dead; on its being opened, the 
heart was found to be beating, although irregularly and 
very feebly. 

Experiment 10. — Cat. 

12.16 P.M. — Temperature of box, 130°. 

12.35 P.M. — Temperature of box, 130°. The cat ever since 
having been put in the box has been struggling violently 
and savagely, and for the last five minutes has been evi- 
dently growing weaker, but perfectly conscious. Just seized 
with a sudden tetanic convulsion, which instantly arrested all 
respiration, and persisted with absolute rigidity for about five 
minutes (notby actual timing). When the cat was taken from 
the box the pupils were widely dilated, the heart beating 
strongly and regularly. She was plunged into cold water, 
but never made an effort at breathing, although perfect 
relaxation of the muscles soon came on. The body was 
opened ; heart found to be still beating and distended with 
blood ; after a considerable time it was seen to gradually 
stop beating, and the left side contracting expelled all the 
blood from it, and became rigid under our eyes. The dia- 
phragm responded, though somewhat feebly, to the gal- 
vanic current fully fifteen minutes after respiration had 
ceased. 

These experiments confirm in many respects the 
results of previous observers, but they also show 
that the rigidity of the heart and of the muscles is often 
not ante mortem^ but post mortem^ occurring some- 
times at the moment of death, at other times not 



40 



THERMIC FEVER, OR SUNSTROKE. 



until some minutes after it. In all those cases in 
which an especial observation of the point was made, 
respiration ceased before the heart's action. In Ex- 
periment 8, the pigeon was opened directly after 
death, and the pulsations of the heart watched for 
some time. In Experiment lo the same thing was 
done upon a cat. In this case, the heart under- 
went the process of hardening beneath my view. 
The change was a quick but not instantaneous 
one ; the viscus appeared gradually to shorten 
itself, and to become at the same time less broad, 
and put on a very rigid look, — the whole process 
taking perhaps about half a minute to complete 
itself This experiment w^as also interesting as 
showing that the diaphragm does not lose its func- 
tional power before death, nor is aKvays the first 
muscle in the body to do so. 

Experiment lO was of great interest on account 
of the sudden seizure resembling so closely certain 
forms of sunstroke in man. The symptoms were 
evidently not of muscular origin, the heart per- 
sisting in its regular beat long after respiration had 
been arrested by a tetanic spasm, from w^iich the 
muscles after a time completely relaxed, and the 
diaphragm responding to electricity fully fifteen 
minutes after the cessation of respiration. 

Muscular System, — As the very rapid post-mortem 
rigidity of the voluntary and involuntary muscles is 



NATURE. 



47 



certainly among the most prominent and character- 
istic lesions of sunstroke, it is evident that a study of 
the causes or nature of post-mortem rigidity is most 
vital to a discussion of the nature of the affection. 

Three theories have been advanced to explain 
this rigidity. The first is, that it is a sort of 
vital contraction, allied to the normal contraction, 
which has become permanent. This vitalistic idea 
has been recently placed in its most definite, tan- 
gible form at the hands of Chas. Bland Radcliffe, 
who has formulated the following proposition : 
'* Rigor mortis, like ordinary muscular contrac- 
tion, would seem to be caused by the elasticity 
of the muscular fibres being allowed to come into 
play by the disappearance of the electrical charge 
which had previously kept these fibres upon the 
stretch, the contraction in rigor mortis being per- 
manent simply because this disappearance is final." 
Another vitalistic theory, essentially different from 
that of Radcliffe, is the so-called idio-muscular 
theory of Schiff, according to which an acrid acid 
juice is developed by a commencing decay of cer- 
tain portions of the muscles, and acts upon the 
remaining sound portion as a stimulant, causing 
persistent contraction. 

It would be digressing too widely to discuss 
the general theory of Radcliffe as to muscular con- 
tractility. It suffices for my purpose to deduce 
the following objections, which, in the absence of 



^8 THERMIC FEVER, OR SUNSTROKE. 

any proof in favor of it, seem to me fatal to a 
theory which associates normal vital contractility 
and post-mortem rigidity. 

The physical conditions of the contracted muscle 
are very different from those of the rigid one. Thus, 
the elasticity of the two is entirely different : the 
contracted normal muscle stretches, the rigid one 
breaks. Kiihne has shown, and Harless (Unter- 
suchungen an der Muskelsubstanz ; Sitzungsberichte 
derbayer. konigl. Akad., i860) has confirmed, that 
whilst the tetanized muscle is translucent, the rigid 
one is turbid and opaque, and the turbidity has been 
proven to come on pari passu with the rigidity. 
Dr. Harless experimented so as to show beyond 
cavil the simultaneous occurrence of opacity and 
rigidity, in the following way. A piece of frog's 
muscle was tightly placed between the compresso- 
rium plates under a microscope, and a stream of 
light thrown through it just sufficient in power to 
bring out distinctly the lines of a cobweb microm- 
eter in the eye-piece. It was found, on heating 
the fragment of tissue, that at from 36° to 40° 
Cels. (=96^° to 104° F.) the cobwebs were lost to 
sight from the muscle becoming less transparent 
(loc. cit, p. 128). 

Herrmann and Walker, who have recently (Pflu- 
ger's Archiv, ii. 182, 195) called attention to the 
difference in the contraction of post-mortem rigidity 
and that of living muscle, state that whilst the living 



NA TURl 



49 



muscle will raise a weight much higher than occurs 
during post-mortem hardening, during the latter 
process a heavier weight will be lifted than the 
most powerful electrical stimulation will induce the 
livn'ng muscle to elevate. 

The second objection to the theory of identity 
of rigor mortis and muscular contractility was first 
urged, I believe, by Dr. Harless (Untersuchungen 
iiber die Muskelstarre, Sitzungsberichte derkonigl. 
bayer. Akad., i860, p. 456.) It is as follows: If 
the loss of irritability of a separated muscle be 
expressed by a curved line, the curve at first sinks 
gradually and towards the close abruptly, or, in 
other words, the irritability at first lessens very 
slowly, afterwards very rapidly. Now, if, as the 
vitalistic theory contemplates, the irritability and 
post-mortem rigidity are, as it were, complementary, 
a curved line expressing the growth of the latter 
ought to be similar to that expressing the growth 
of the former, — i.e. a curve at first gradual, after- 
wards sudden. This, however, does not happen^ 
but from the beginning the muscular currents, 
which are an inverse index of the post-mortem 
rigidity, lessen with decreasing rapidity. It would 
appear at first as though Morgan (Electro-Phys- 
iology and Therapeutics, p. 327) expressed a 
different belief from this of Harless as to the re- 
lations spoken of, for he says, *' The diminution 
of the muscular current is directly as the de- 

5 



CO THERMIC FEVER, OR SUNSTROKE. 

crease of the irritability of the muscle." It appears, 
however, that Dr. Morgan does not mean this to 
be construed too hterally, for in his diagram (Fig. 
lOi) the curves representing the loss of muscular 
currents follow the law of Harless. 

Kiihne also found by experiment that the ex- 
pressed acrid juice of dead frog muscle has no 
power to cause contraction of living frog muscle. 
Evidently a coup de grace to Schiff's theory. 

As early as 1842, Briicke (Ueber die Ursache des 
Todtenstarre, Muller's Archiv, 1842) accounted for 
the occurrence of post-mortem rigidity by the co- 
agulation of a plasma in the muscle ; he, however, 
failed to prove his supposition. The difficulty he 
met with was, that whenever he attempted to press 
out the plasma from the muscle, the change would 
take place whilst the latter was in the press, and he 
would obtain only rigid muscles and an acid juice. 

In 1859 Kuhne took the matter in hand (Un- 
tersuchungen iiber Bewegungen und Veranderun- 
gen der contraction Substanzen, Reichert und Du 
Bois Reymond's Archives, 1859, p. 564), and suc- 
ceeded in overcoming the difficulty by the use of 
salt and cold, both of which agents have the power 
of retarding muscular rigidity. He first washed the 
blood out of the muscles of frogs by injecting 
through the arterial system of the animal just killed 
a one to two per cent, solution of salt ; then cut the 
flesh into small pieces, washed it with salt water. 



NA TURE. 



51 



and put it in a cold press. By this means he ob- 
tained a glairy fluid, which near the freezing tem- 
perature remained liquid, but at 40° C. (104° F.) 
instantly formed a large, firm, translucent coagu- 
lum. At a temperature of 35° C. (95° F.), coagu- 
lation occurred in an hour; at 38° C. (iOo|-° F.), in 
half an hour; and at from I2°-I4° C. (531-58° F.), 
at the end of six hours. 

Kiihne also performed similar experiments upon 
a rabbit with similar results, obtaining a glairy 
h'quid, which coagulated after standing three or 
four hours at an ordinary temperature. 

I have repeated the experiment of Kiihne on a 
rabbit, with results similar to his. 

Experiment i i . — November 15,1871. A full-grown rab bit 
was killed by a blow on the back of the neck. It was opened 
immediately, and salt water was thrown into the descending 
aorta so as to come out of the vena cava ascendens. The 
muscles were then cut into small pieces, thrown into salt 
water, and put immediately into a press. The liquid first 
obtained was rejected ; it was thin and pinkish ; afterwards, 
under strong pressure, a clear, slightly pinkish viscid fluid 
was procured. The reaction of this was neutral ; but on 
exposure of the wet litmus-paper to the air, the acid re- 
action was soon developed. This fluid was gradually 
warmed, and when 115° F. was reached at once changed 
color, became whitish and somewhat turbid; at 116° F. 
there was decided coagulation. If 110° F. was maintained, 
in the course of a very few minutes coagulation took place. 
After coagulation the reaction was decidedly acid. 



52 THERMIC FEVER, OR SUNSTROKE. 

Dr. Pickford (Henle und Pfeuffer's Zeitschrift fiir 
ration. Medicin, Neue Folge, i.) was, I believe, the 
first to notice that a frog's muscle would become 
rigid when placed for a few seconds in a liquid 
heated to 65° R. (= 1781° F.), or for some min- 
utes in one at 30° R. (= 99^° P.). 

Schiff (Lehrbuch der Physiologic) and Mundt 
(Die Lehre der Muskelbewegung) confirmed this, 
but to Kiihne belongs the credit of having first 
thoroughly investigated the subject, in the paper 
already quoted. He found (loc. cit., p. 789) that a 
muscle of a frog plunged into a liquid of 65° R. 
or 82° C. (= 178^° F.) for twenty-five seconds be- 
came permanently rigid; and that if a muscle were 
left for a whole minute in a liquid at the temperature 
of about 45^ C. (= 113° F.) the same result fol- 
lowed. Further, that if the muscle were immersed 
for some minutes in quicksilver at a temperature 
of 37.5° C. (= 100° F.) it lost its power of con- 
tracting under the influence of the strongest gal- 
vanic stimulus, and yet remained limp, and with 
an alkaline reaction. By a still longer immersion 
it became perfectly rigid. M. Kiihne also states 
that immersion of a frog's muscle in quicksilver at 
a temperature of 40° C. (= 104° F.) produced 
almost instantaneous rigidity. This was also found 
to take place in a living frog when the legs were 
placed in quicksilver at 40^ C. (= 104° F.); and 
although the circulation was perfectly re-established, 



NA TURK, 



53 



and the frogs kept alive, the muscles never in any 
sense recovered themselves, — never regained any- 
contractile power. The lowest temperature by pro- 
longed exposure to which the frog's muscles lose 
their functional ability is between 35° and 37° C 
(=95° and 99^ F.). 

On the other hand, an exposure of the frog's 
muscles to a low temperature protracted the period 
of sensitiveness to stimuli, so that under such con- 
ditions the muscles would remain active for days. 

With these facts the coagulability of the muscle 
fluid was found in complete accord. Near 32° F. 
it remained clear and liquid for days ; at 40° C. 
(=104° F.) it instantly coagulated; at 30° C, 
(=86° F.) coagulation occurred in an hour; at 
38° C. (= loof^ F.) in half an hour. The reac- 
tion of the heated muscle was acid, and it was 
also found that a frog's muscle which had under- 
gone spontaneous rigidity, or one that had become 
rigid by the sudden application of a heat of 40° C. 
(= 104° F.), could be rendered more rigid by a 
heat of 45° C. (=113° F.). Kuhne also found 
that, even if the frog's muscle had commenced to 
decay, it was changed (by a heat of 45 ° C.) into a 
hard, whitish mass, and also that he could press 
out from thoroughly rigid muscles an acid juice, 
which had no tendency to coagulate at ordinary 
temperatures, but which does undergo immediate 
coagulation at 45° C. These facts certainly seem to 



54 



THERMIC FEVER, OR SUNSTROKE. 



show that whilst the rigidity produced by a tem- 
perature of 40° C. (= 104° F.) in a frog's muscle 
is the same in nature with post-mortem rigidity, 
that produced by a temperature of 45° C. (= 113° 
F.) is of a different nature, and depends upon the 
coagulation of a distinct albuminoid substance. 

In the Sitzungsberichte der konigl. bayer. Aka- 
demie der Wissenschaften, June, i860, Herr E. 
Harless published the elaborate paper which I 
have already quoted (see page 48), in which 
he corroborates in the main the statements of 
Kuhne. He succeeded without trouble in ob- 
taining the muscle plasma musculin in quantity, 
and found it a nitrogenous substance more closely 
allied to casein in its behavior with reagents (p. 
lOl) than to the other albuminoids. He also 
found that the coagulation temperature is in warm- 
blooded animals near 45° C. (=113° F.), and that it 
varies in different animals, and in the same species 
under different circumstances (p. 100). Thus, in 
different rabbits he found it ranged from 42^-48^ 
C. (= io7f°-ii6|° F.); in frogs, from 30^-44° 
C. (=86^-1 1 1 i° F.); in a calf, from 45^-46° C. 
(=113°-! 16° F.) ; and whilst in a very old cat 
45° C, in a newly-born kitten it was 70° C* 
(=I58°F.)! 

He also found (p. in) that the formation of the 

■^ This is evidently a misprint. 



A' A TURK, 



55 



acid precedes the commencement of coagulation, 
taking place 4^-5° Cels. (8°-io° F.) below the 
temperature that the latter occurs at, and occur- 
ring sooner when the fluid is allowed to coagu- 
late spontaneously. When the acid forms it alters 
very materially the color of the liquid, and by set- 
ting the latter aside in a glass vessel in a cool room 
he was enabled to watch the change into a deep 
reddish-brown liquid, occurring in from twelve to 
twenty-four hours, whilst not a trace of turbidity 
existed. This change of color I myself have noted 
as occurring just before coagulation, and think 
therefore that Morgan (loc. cit., p. 329) is mistaken 
when he says the coagulation of the muscle fibrin 
precedes this acidity; a mistake which might very 
well have been a mere slip in the manuscript, and 
it is well known he did not live to read the proof. 
In a second paper in the Sitzungsber. der k. bay. 
Akad. d. Wissensch., i860, entitled '' Untersuch- 
ungen uber die Muskelstarre," Harless attempts to 
establish the theory that although coagulation of 
the myosin and post-mortem rigidity occur at the 
same temperature and consentaneously, the latter 
is not due to the form.er, but to a physical action 
of the acid developed upon the muscular fibrillse, 
shrinking them up. I do not think, however, he 
succeeds in establishing this, and believe that it is 
disproven by the facts that in some muscles the 
acidity does not develop (see Morgan, loc. cit., p. 



eg THERMIC FEVER, OR SUNSTROKE. 

329), and that washing the acid out of a muscle by 
an alkaline solution will not restore its contractility 
when rigidity has fully set in. There can be no 
doubt, however, of the close connection between 
the acidity and the coagulation of the myosin. 
A circumstance illustrating this, mentioned by 
Morgan (loc. cit, p. 333), is the action of a ten per 
cent, solution of common salt on a rigid muscle. 
This dissolves out the myosin, and leaves the 
muscle limp and translucent, and at the same time 
free from acid reaction. 

The only objection to the coagulation theory 
worthy of notice is found in the circumstance that 
muscle which has become rigid after the cutting 
off of the circulation from it, can be made to- regain 
its pliability and contractility by removal of the 
arterial ligature, or that muscle which has become 
rigid after the death of the animal can be restored 
by the injection of warm blood. As early as 1834, 
Dr. Jno. P. Kay (Treatise on Asphyxia, p. 143) 
noted that if the circulation was arrested in a limb, 
the muscles soon lost their power of contracting 
under the influence of galvanism, but recovered it 
when the obstruction to the passage of the blood 
was removed. 

His experiments have been repeated and ampli- 
fied by various observers, especially by Brown- 
Sequard (Comptes Rendus, June, 185 i) and Prof 
Stannius, of Rostock (Archiv fiir phys. Heilkunde, 



NA TURE, 



57 



1852). The experiments of the first of these ob- 
servers were made both on man and animals; the 
details it is needless here to speak of, but the results 
arrived at were, that cadaveric rigidity in animals 
could be overcome after it had lasted from ten to 
twenty minutes, and in man a muscle which had 
been rigid for nearly two hours could be restored. 
I have not seen the original account of Prof. Stan- 
nius's experiments, but, as quoted, they are very 
similar to those of Brown-Sequard, and the results 
arrived at only differ in so far that Stannius suc- 
ceeded in restoring the hind legs of a puppy which 
had been stiff and cold for one hour. It is this 
possibility of restoration which has been urged as 
an objection to the plasmic theory. As stated by 
Kuhne, however, it does not seem to be a fatal ob- 
jection. The first coagulation of the muscle plasma 
does not necessarily imply the immediate death of 
the fibre. And it is conceivable that while in a 
condition of partial coagulation, as it were, the 
plasma might yield to the solvent powers of the 
warm alkaline blood and the renewed activity of 
the surrounding life forces, and be brought into 
such a state as to be removed, especially as it has 
been shown that the miyosin can be washed out 
and the muscle rendered limp by a strong solution 
of salt. In Brown-Sequard's experiments it was 
found that the blood changed its color from arte- 
rial to venous during its passage through the arm, 



58 THERMIC FEVER, OR SUNSTROKE. 

showing that vital action was recommenced. Fur- 
ther, it is implied by the experiments both of Brown- 
Sequard and Stannius, and definitely proven by 
those of Kijhne (loc. cit.), that there does come a 
time when the rigid muscle cannot be restored, 
although through the unbound artery the blood 
courses into the capillaries and veins with steady, 
free, persistent current. If the contraction were a 
vital phenomenon, this could not be, because the 
muscle should relax as soon as dead, and, not 
being dead until relaxed, whilst still rigid ought to 
be capable of restoration. In this view, then, the 
assumed objection is rather a confirmation than a 
valid objection to the plasmic theory. 

This being so, I feel forced to accord assent to 
the proposition, that tJiennic and post-mortem rigid- 
ity are alike due to tlie coagulation of a plasma in the 
muscles. 

This proposition being acceded, the question 
naturally presents itself. Is death in sunstroke due 
to the coagulation of the plasma by heat? 

It is evident that in determining this question at 
least two lines of approach are open, — the one, 
that of absolute ocular and palpable examination, 
determining whether or not the heart does stop 
before respiration, and whether the muscles are 
absolutely dead before general death; the other, 
the comparative study of the temperatures at which 



NA TURK. 



59 



coagulation of myosin occurs, and of the death 
temperature in fatal heat or sunstroke. 

Along the last of these roads I shall first ap- 
proach. Vallin (loc. cit., p. 143) believes that co- 
agulation of the myosin is the cause of death. 
He says, — after detailing the fact that muscles 
always become rigid at 45° 0.(113'' R), — ''The 
death has always taken place at the precise mo- 
ment that the temperature of the blood attains 45° 
C, and a thermometer introduced into the cavity 
of the heart did not vary more than some tenths 
of a degree above or below this point; so that it 
affords, as it were, a sort of natural realization of 
the coagulation of a muscle by plunging it into 
water at 45° C. The diaphragm, after the heart, 
is the muscle which becomes rigid the most quickly, 
and all the world acknowledges, after Claude Ber- 
nard, that the point of greatest heat in the body is 
where the vena cava traverses the diaphragm. It 
is easy, then, to understand why at death the heart 
and diaphragm are rigid, whilst the muscles of the 
trunk preserve their contractility. Coagulation com- 
mences with the left ventricle, which becomes rigid 
and immovable; its cavity is effaced, and hence is 
explained the relative arterial anaemia which all the 
organs present. The right ventricle becomes rigid 
more slowly and irregularly, and preserves in some 
cases for a time its activity, so that the blood of 
the pulmonary circulation, not finding access to 



6o THERMIC FEVER, OR SUNSTROKE. 

the left ventricle, accumulates in the lungs, pro- 
ducing an enormous congestion, and sometimes 
rupture. Further, the inertia, or, to speak more 
accurately, the rigidity, of the diaphragm interferes 
with the respiration, and adds the effects of asphyxia 
to those produced by stoppage of the heart." 

The temperature at which myosin coagulates 
has already been shown to vary, but to be in warm- 
blooded animals often above 45° C. or 113° F. 
The testimony of Vallin, that the death tempera- 
ture agrees with this, has just been cited, and in 
another place in his memoir (p. 139) he says the 
temperature at the moment of death varies from 
44° C. to 46.1° C. Claude Bernard states that the 
death temperature ranges from 43° C. (109!^ F.) 
to 45° C. (113° F.). Dr. Stiles says the tempera- 
ture never rose above 115° F., and was often one 
or two degrees below it. 

The testimony of Vallin must be received with 
some guardedness, as lie is so fully committed to the 
support of a theory. It will be seen that the experi- 
ments of both the other authorities indicate that 
whilst in some cases 113° F. is attained, in many 
others the death temperature is much below it. 
My own experiments, already detailed, confirm 
this testimony, the rectal temperature at death 
varying from 1 11° to 114° F. 

Dr. T. Lauder Brunton, in experiments reported 
in St. Bartholomew's Hospital Reports, vol. vii., 



NATURE. 6 1 

states that the upper limit at which the heart, when 
heated, stands still varies in different cases, but 
that in the stronger animals it is between 1 13^ and 
114° F., and even above. He has seen the heart, 
however, beating actively at 1 1 5° F., and still under 
the influence of the vagus nerve. These tempera- 
tures, however, he remarks, were taken in the 
rectum, whilst the arrangement of the heating 
apparatus was such that the probabilities are the 
temperature was somewhat less in the thorax than 
in the abdomen. His results, I think, are further 
vitiatedby the fact that the animals were all nar- 
cotized either with chloral or opium. In pigeons 
the fatal temperature was always up to 120° in my 
experiments; but there can be no doubt that the 
coagulation point of myosin in these birds is higher 
than in mammals, as their normal temperature is so 
much higher. They must therefore be left out of 
consideration in discussing the question in regard 
to mammals. 

From these different views of the subject it may 
be safely inferred that in some cases where an 
animal is killed by overheating, the temperature 
reached during life is that at which myosin removed 
from the body coagulates, but in others it is a de- 
gree or two below the point. 

Further, it seems very probable that the myosin 
influenced by life forces, and by the steady alkaline 
current of the blood, would resist a heat in living 

6 



62 THERMIC FEVER, OR SUNSTROKE, 

muscle which would coagulate it instantly under 
other conditions. Confirmatory is the statement 
of Dr. Brunton, already cited, that he has seen the 
heart beating fairly and still under the influence of 
the vagus when the thermometer in the rectum in- 
dicated 115° F. 

Looking at the question under consideration 
solely from this point of view, the answer is some- 
what doubtful, but appears to be that in some cases 
it is very possible that death of the animal may be 
due to direct coagulation of the cardiac myosin 
by heat, whilst in other cases it is most improbable. 

It is very possible that the mode of applying the 
external heat, and especially the intensity of the 
latter, may affect the result. Certainly my own ex- 
perience is much opposed to the idea that a bodily 
temperature of 115° F. is often attained in killing 
cats and rabbits by heat. 

The second means of deciding the question leads 
in a more positive manner to a definite conclusion. 
My own experiments were carefully made with a 
view of determining the matter, and were very uni- 
form in the result. 

In no case that was closely studied did the heart 
cease to beat before arrest of respiration. In Ex- 
periment I the heart beat very feebly and imper- 
fectly after the opening of the cadaver; in Experi- 
ment 2 the animal may have been dead fifteen 
minutes before the autopsy. In Experiment 3 the 



NA TURE. 



63 



heart was found beating quite actively after death, 
and was seen to become suddenly rigid. In Ex- 
periments 4, 5, and 6, on pigeons, the pulsations 
of the heart could be felt continuing after the cessa- 
tion of respiration. In Experiment 7 the thorax 
was opened and the regular beat of the heart 
ocularly demonstrated after respiration had ceased. 
In Experiment 8 death took place from a centric 
convulsion, and the heart went on for some ten 
minutes with a strong, vigorous beat. 

Further, if it be true that an animal dies from 
coagulation of the myosin of the heart, it is very 
apparent that if, by any artificial means, it can be 
cooled before such coagulation has occurred, whilst 
the heart is still beating, recovery must result, or 
at least death be averted for the time. 

That an animal may, however, be cooled down 
to its normal temperature, whilst the heart is beat- 
ing, and yet the fatal result be in no very perceptible 
degree postponed, is shown by the following experi- 
ment: 

Experiment 12. — Pigeon put in hot box at 1.53 p.m. 
Temperature, 114°. At 2.14 the temperature was 1 17°. The 
pigeon was now taken out of the box very ill, imable to 
stand, but with the heart beating regularly. It was plunged 
into cold water, and the temperature reduced to 105°. It 
did not, however, revive any, and died in some ten minutes. 

The results of my experim.ents viewed alone are, 
then, very positive, that death does not generally 



64 THERMIC FEVER, OR SUNSTROKE. 

occur from coagulation of the cardiac myosin, but 
from arrest of respiration. 

Claude Bernard (loc. cit., p. 134), on the other 
hand, says, " It appears still very possible, at least 
probable, that there is a coagulation of the myosin, 
and that this is the cause of the death of the mus- 
cles, and of the heart in particular. The manner 
in which heat causes death is, then, perfectly ex- 
plained. However, as the animals can be taken 
from the stove a few moments before the fatal issue 
and not die for many hours, or even for many days, 
it seems necessary to admit that there are many 
other grave alterations produced by the heat." 

Modifying my own results by those of Claude 
Bernard and Vallin, I think the following proposi- 
tion expresses the truth : 

Death in the lower animals from sunstroke or 
heat fever, not produced by a sudden intense heat, 
occasionally is the result of coagulation of the 
cardiac myosin ; but in many instances, and prob- 
ably in the majority of cases, is not so produced, 
but is the result of arrest of respiration. 

If it be true that when an animal is kept in the 
intensely heated atmosphere until death, it suc- 
cumbs often from other causes than the coagulation 
of the muscular plasma of the heart, it would seem 
that much more frequently would man suffer and 
die from these other causes. His nervous system, 



NA TURE. 



65 



especially the cephalic, is so much more susceptible 
that it would be expected to suffer more than that 
of the animal. More than this, in the experiments 
I have detailed, the external heat is steadily kept 
up until death, and hence the body of the animal 
attains the maximum temperature. Not so with 
man; very generally the external heat is removed, 
but death takes place nevertheless. 

It is necessary, therefore, to study the effects of 
heat on man separately from that on animals, to 
determine whether death does result from coagula- 
tion of the myosin of the heart; and I shall ap- 
proach the subject as before. 

First, then, what temperature is attained in cases 
of insolation or coup de soleil ? 

Unfortunately, very few close clinical records 
have been kept which can throw light on this point. 
In India, especially, the suddenness and epidemic 
nature of the affection, the fact that it mostly occurs 
during the most laborious and trying periods of 
campaigns and marches, and the circumstance that 
the doctor is himself generally on the border of an 
attack, all combine to prevent any clinical work 
beyond what is necessary for the safety of the 
patients. 

The following table, taken from Dr. Levick's paper 
in the Pennsylvania Hospital Reports for 1868, 
represents, however, sufficiently the disease as it 
occurs in the United States: 



66 



THERMIC FEVER, OR SUNSTROKE. 



TABLE OF TEMPERATURES. 



Case. 
I. 



Place. 
New Orleans. 



Philadelphia. 



Observer. Te7np. Max. observed.* 

Dowler. 113° F. 

109° 
*' 104° after death. 

" 110° after death. 

106° 
Levick. i09-5° 

109° 
106° 
105.5° 
" 112° after death. 

H. C. Wood, Jr. 108° 

108° after death. 
109° . 
«♦ 104° 

106° 
" 109°-! 10° after death. 



An examination of this table will show that in 
no case was a temperature anywhere near 115° F. 
reached, either before or after death ; and that in 
the large majority of cases the highest point at- 
tained was not within six degrees of that degree; 
although it is very probable that the temperature 
given does not always represent the actual maxi- 
mum, yet the evidence seems irresistible that in the 
majority of cases of insolation in man the bodily 
heat does not become sufficient to coagulate the 
cardiac myosin. The results of observation are in 
close concord with this conclusion. Earlier in this 



■^ Proof seems wanting that the temperatures noted were actually 
the highest attained in all cases. 



NATURE. 



67 



paper I discussed the modes of death in sunstroke, 
and it was, I think, clearly proven that in the gen- 
erality of cases death is immediately produced by 
a failure of respiration, or by a gradual consenta- 
neous failure of respiration and circulation. 

The conclusion seems to follow inevitably that 
in the ordinary forms of human sunstroke death is 
not due to the coagulation of the cardiac myosin, 
and that the latter change and consequent hard- 
ening of the heart is a post-mortem phenomenon, 
occurring directly after death. 

In the discussion of the clinical history of sun- 
stroke, it was ^stated that there is a distinct class of 
cases in which syncopal death occurs suddenly. 
A study of these cases is evidently here in order. 

It is a fact well known to sportsmen that rigor 
mortis comes on with extraordinary rapidity after 
severe muscular exertion. A rabbit or hare which 
has been run for several miles by a dog will, on 
being shot, perhaps, roll over once or twice and 
be picked up perfectly stiff. The same thing has 
been observed in the tetanus produced by strychnia, 
the spasmodic muscles being said to sometimes 
become rigid even without relaxation. Of these 
facts there can be no doubt, as they are testified to 
by every investigator. (See Hermann, Grundriss 
der Physiologic des Menschen, Berlin, 1870, p. 228.) 

The explanation of this, if the theory of post- 
mortem rigidity herein advocated be correct, is 



68 THERMIC FEVER, OR SUNSTROKE. 

that the myosin under such circumstances under- 
goes some peculiar change by which its tendency 
to coagulation is increased. 

Dr. Harless (loc. cit.) has experimentally proven 
this to be the case, for he found that myosin pre- 
pared from a rabbit tetanized with strychnia coagu- 
lated at 42° C. (i07|-° F.), whilst that from a similar 
non-tetanized rabbit did not change until 48° C. 
(ii8|° F.) was reached. 

Certain experiments which I have performed 
would seem to illustrate this fact by its opposite. 
In Morgan's work (loc. cit, p. 332), the following 
method of preparing myosin in large quantities is 
given : '* Enough common salt in powder is mixed 
with snow in a cold vessel to form, when thawed, a 
one per cent, solution, and this mixture rubbed up 
intimately with one-fourth of its weight of shavings 
of frozen frog's muscle is, while still at 3° C, 
thrown on a piece of linen ; then the liquid is 
filtered several times through paper wet with a 
cold one per cent, solution of common salt set in a 
cold glass funnel, and each time the filter clogs 
a new one is substituted for it." 

I followed this process, but not so closely, per- 
haps, as I ought, straining only through the linen, 
and perhaps having the salt in excess ; and got a 
thick, syrupy liquid, which did not undergo distinct 
instantaneous coagulation at a lower temperature 
than 1 13° F. The frogs I used were frozen almost 



NA TURE. 



69 



stiff, and had been absolutely torpid for months, 
and to this circumstance I attribute the slight tend- 
ency of the myosin to coagulate, so that the propo- 
sition may be stated that lo7ig rest of a muscle 
dimmislies the tendency of myosifi to coagulate. 

It is very plain a priori \k\dl these facts must be 
true of man, if of animals; and clinical observation 
certainly confirms them. 

As a proof of this it is only necessary to refer 
to a paper on ''Instantaneous Rigor as the Ac- 
companiment of Sudden and Violent Death," by 
Dr. Jno. H. Brinton, in the American Journal of 
Medical Sciences, 1870, p. 1870. In this exceed- 
ingly interesting memoir the sudden occurrence of 
such instantaneous rigor is very clearly proven by 
the testimony of the author and other eye-witnesses 
as being frequently seen on battle-fields. Under no 
circumstances is the excitement more intense, or 
the muscular system more strained, than on the 
field of battle ; so that the evidence is certainly 
complete that both in man and animals excessive 
exertion predisposes to coagulation of myosin, 
and renders it liable to alter at a temperature 
decidedly below the normal point of change. 

The cardiac variety of sunstroke is said by the 
Indian authorities to occur especially in action, 
rarely during marches, never in barracks. As an 
example of it may be cited the account given by a 
witness to Dr. Parkes, and incorporated in his work 



70 



THERMIC FEVER, OR SUNSTROKE. 



on Hygiene (Pract. Hygiene, 2d edit., p. 360), of 
an occurrence during the first Chinese war. The 
98th Regiment was marching on a very hot day, 
and the surgeon who was with the rear-guard 
stated to Dr. Parkes that the men fell suddenly 
on their faces, as though struck with lightning, 
and, on running up and turning them over, many 
of them were already dead. Dr. Maclean, who 
was present at this occurrence, confirms the ac- 
count given by Dr. Parkes, but states that it was 
at the attack on Chian-Kiang-Foo. The men 
were thickly clothed, with tight accoutrements and 
tight, rigid stocks, and were charging up a very 
steep hill. A great number of them were stricken 
down, and fifteen died instantly, falling on their 
faces, and giving merely a few convulsive gasps. 

The points worthy of note in this history are, — 
first, that the men were making violent exercise 
going up-hill, so that the heart must have been in 
exceedingly active exertion, increased by the im- 
pediment to the circulation afforded by the tight 
accoutrements ; second, that the attacks were in- 
stantaneous and syncopal in their character. To 
my mind the conclusion is irresistible that death 
was produced by sudden coagulation of the myosin 
of the cardiac muscle, and consequent rigid arrest 
of the heart's action. 

Vallin seems to think that the arrest of respira- 
tioit, when it occurs before or simultaneously with 



NATURE. yi 

the cessation of the heart-beat, is due to a coagu- 
lation of the myosin of the diaphragm. I think, 
however, that the disproof of this, except as a mere 
possible rarity, is so plainly contained in what has 
been said about the heart, that it is not necessary to 
dwell upon it. I will merely refer to Experiment 
lo, in which, although the cat died of sudden arrest 
of respiration, the diaphragm distinctly reacted to 
the stimulus of galvanism fifteen minutes after 
death, and also to the fact that is shown in my 
clinical records, that in man general muscular rigid- 
ity is often not developed within the first hour after 
death from insolation. 

The prolonged study of the muscular system in 
insolation has, then, produced the following conclu- 
sions : 

1st. Excessive rigidity of heart, due to a coagu- 
lation of its myosin, is a very pathognomionic lesion 
of sunstroke. 

2d. That in most cases it is a post-mortem, rather 
than an ante-mortem, phenomenon, occurring di- 
rectly after death. 

3d. In certain cases, the so-called cardiac variety 
of sunstroke, death is probably due to a sudden 
ante-mortem coagulation of the cardiac myosin, 
and consequent instantaneous arrest of the heart's 
action. 

4th. That the muscles after death from heat 
fever very soon become rigid, sometimes do so 



72 THERMIC FEVER, OR SUNSTROKE, 

instantly, and that such rigidity is of the same 
nature as ordinary post-mortem rigidity. 

5th. That while it is conceivably possible that 
death from asphyxia may occur from coagulation of 
the myosin of the diaphragm and other respiratory 
muscles, it is exceedingly probable that in man 
death never does actually occur from such cause. 

Nervous System. — Having completed the study 
of the action of heat upon the muscles and their 
pathology, so to speak, in sunstroke, it seems next 
in order to take up the nervous system. To any 
one who has witnessed a case of coup dc soleil, the 
importance of such investigation must be most 
obvious. What is required is the determination 
how far the nervous symptom.s are produced di- 
rectly by the heat, and how far they are the result 
of antecedent changes in the blood. The first step 
in such inquiry must logically be the endeavor to 
find out whether the degree of heat manifested in 
sunstroke will of itself produce nervous symptoms; 
and if so, how these will compare with those of 
coup de soleil. 

This endeavor also naturally divides itself into 
two parts : first, the study of the action of heat on 
the nerve-centres ; second, the investigation of its 
action on the nerve-trunks. 

There is no difficulty in applying heat directly 
to the brain of the cat and rabbit by surrounding 



NATURE. 73 

the head with a double bonnet of india-rubber, or, as 
I have used, of pig's-bladder, and allowing hot water 
to run through this. Vallin is, so far as I know, the 
only observer who has made any such experiments. 
It is evident that there are two points especially to 
be determined in this inquiry: first. How do the 
symptoms produced compare with those of ordi- 
nary coup de soleil? second. What is the tempera- 
ture at which the functional power of the brain is 
lost? In only two instances did Vallin succeed in 
causing death by the hot-water bonnet, and in 
neither of these cases was any attempt made to 
measure the temperature of the brain. The symp- 
toms are not described by Vallin as closely as is 
desirable, but appear to have been insensibility, — 
whether coming on gradually or suddenly is not 
stated, — with convulsions. 

My own experiments are as follows : 

Experiment 13. — A full-grown rabbit. Rectal tempera- 
ture I02j°. 

Time. Temp, of Water. Remarks. 

1 2. 1 1 140° F. 

12.49 1750 F. Puffiness and great swelling of the scalp, 

with very hurried respiration and ex- 
ceedingly rapid pulse, with violent 
struggles, constitute the only effects as 
yet produced. 

12.51 175° F. A sudden, severe convulsion, followed by 

a state of semi-unconsciousness. 
1.4 150° F. Rectal temperature, 104^°. 

7 



Time. 


Te7np. of Water. 


I.IO 


140° F. 


1. 15 


180° F. 


1.20 





74 THERMIC FEVER, OR SUNSTROKE, 

Remarks. 
Lies quiet, semi-unconscious ; but the 

corneas are very sensitive. 
Convulsions. 
Died in a stupor, a gradual deepening 

of the previous semi-unconsciousness. 

The respiration ceased before heart's 

action. 

Autopsy. — Skull opened instantly, just sufficiently to allow 
a thermometer to be plunged in the brain ; it indicated 1 17° 
F. The heart was soft and flaccid ; the right side full of 
blood, the left empty. The muscles responded well to gal- 
vanic stimulus, but rigor mortis set in in a few minutes. 

Experiment 14. 

Time. Temp, of Water. Anal Te7np. Remarks. 



12.38 


190° F. 




12.50 


140° F. 


103I0 F. 


1.05 


135° F. 




1. 15 




104^0 F. 


1.20 


174° F. 




1.30 







Pupils not contracted. 

Before this there have been 
struggles, apparently semi- 
convulsive, and contracted 
pupils. Now a true con- 
^^~~ — ~ vulsion, follov^ed by uncon- 

sciousness and complete re- 
laxation. The breathing is 
accompanied by fine, sonor- 
ous rales. 
1.50 150° F. 106° F. The rabbit has lain for some 

time in a perfectly comatose 
state, with occasional con- 
vulsions. The hot-water 
bonnet was now removed 
from the head, and cold 
water poured over the latter ; 
almost immediately the ani- 



NA TURK. 



75 



mal showed signs of recover- 
ing, and after awhile did so 
- , perfectly. The next day, ex- 

cepting in regard to the local 
trouble in the scalp, etc., the 
rabbit seemed well. 

Experiment 15. — A young, half-grown cat. The hot- 
water bonnet was adjusted to its head, and the water al- 
lowed to run through it. 

Time. Temp, of Water. Rei7tarks. 

II. 15 1620 F. 

11.25 Cat has had several convulsions not pre- 

ceded by signs of nervous disturbance, 
coming on suddenly and followed by 
insensibility, witii partial anassthesia of 
cornea. 



There have been repeated convulsions, 
during which pupils would dilate some, 
although the eye was in the full blaze 
of sunlight. Almost constant convul- 
sive trembling, affecting very markedly 
even the eye-muscles. The cat is all 
the time absolutely unconscious. Cat 
died at 11.57, the respiration ceasing 
at least four minutes before the heart 
ceased to beat. On opening the body 
the right heart was gorged with blood, 
and, on being cut, the ventricle pul- 
sated again. The brain was opened 
as soon as possible after death. Its 
temperature was 113° F. The muscles 
responded to galvanism not so actively 
apparently as might be, and rigor mor- 
tis came on in about fifteen minutes 
(not timed with watch) after death. 



11.40 


140° F. 


II.4I 


162° F. 


11-55 


170° F. 



Time. 


Temp, of Water. 


IO-35 


175° F. 


II. 


140° F. 


11.30 


1800 F. 


12. 


160° F. 



75 THERMIC FEVER, OR SUNSTROKE. 

Experiment 16. — A very large, powerful tomcat was 
used, and bladder fitted to head at 10.30 a.m. 

Remarks. 



Verv hurried breathinsr. 



Cat is now unconscious ; the unconscious- 
ness came on in a very short space of 
time, but not with absolute abruptness ; 
no convulsions ; respiration slower. 
12.15 1750 F. Cat just dead. The respiration certainly 

ceased before the heart some seconds, 
or probably a minute or two. No con- 
vulsion. 

Autopsy. — Brain opened instantly. The thermometer 
plunged directly into the substance rose above 114° F. ; 
when placed, however, so as to be in contact with the inside 
of the skull, it marked 115^. There was decided, but not 
extraordinary, congestion of the brain. 

As these experiments are painful ones, I have 
not repeated them further. They seem sufficient 
to establish the following conclusions : First, A 
temperature of the brain of from 113° to 117° F. 
is sufficient, if maintained, to produce death in a 
short space of time in mammals by arrest of the 
respiration. Second. That the chief symptoms in- 
duced are insensibility and convulsions, preceded 
by exceedingly rapid respirations and action of the 
heart, and unaccompanied by any general rise of 
temperature. Tliird. That these symptoms come 



NA TUKE. 



77 



on very quickly in all cases, at times with absolute 
abruptness.* 

A point to be borne in mind in comparing these 
temperatures with those fatal to the muscle, is that 
the death is produced by paralysis of the respira- 
tory centres, and that these centres being at the base 
of the brain are farthest from the heat, hence it is 
very probable they may have been one or more 
degrees below the temperature of the cerebrum as 
represented by the degree noted. The resem- 
blance of these symptoms, induced by the local 
application of heat to the head, to the nervous 
phenomena of sunstroke, is very striking, both in 
regard to the symptoms themselves and also to the 
suddenness of their onset. A reference to the ac- 
count of the exposure of cats to a general high 
heat, will show that in these animals the nervous 
symptoms are much more sudden and severe than 
in rabbits ; in fact, approaching what is seen in man. 
A study of the experiments just detailed will show 
that a temperature of 113° to 114° F. is fatal to 
the brain of the cat, 117° F. to that of the rabbit. 

* These experiments also incidentally confirm the modern belief 
that smistroke is not due so much to the direct heating of the head 
by the sun, as to the heating of the general body, for the symptoms 
induced outside of those arising directly from the cerebrum were 
not those of true insolation. The importance of these experiments 
in the interpretation of the nervous symptoms of fever, it would 
be out of place here to dwell on. 

7* 



78 THERMIC FEVER, OR SUNSTROKE, 

The nervous system of the cat is much more ex- 
citable, and much more impressible, than that of 
the rabbit, and consequently feels the abnormal 
temperature more acutely. The brain of a man is 
much more highly organized, and no doubt cor- 
respondingly more sensitive, than that of a cat; 
and if a temperature below 113° F. is fatal to the 
brain of a cat, whose normal temperature is 102^° 
F., it seems very certain that the temperature of 
some cases of insolation (113^ F.) is sufficient in 
itself to cause death in man, whose normal tem- 
perature is 99° F. 

As will be shown hereafter, death in coup de 
soleil is frequently due in a great measure to a 
slow, gradual deterioration of nerve, muscular, 
and hsemic organization; and in such cases the 
fatal result may be brought about without being 
immediately caused by the temperature, without, 
in other words, the lethal nerve heat point being 
reached. 

Nei've-Trunks. — According to Vallin, E. Harless 
published some years since in Henle und Pfeuffer's 
Zeitschrift, 3d B. viii. pp. 122-185, a paper entitled 
*' Ueber den Einfluss der Temperaturen und ihrer 
Schwankungen auf die motorischen Nerven." I 
have not had access to this memoir, but Vallin 
states that no study of the effect of heat upon 
nerve-centres was made, and that the following 



NATURE, 



79 



results were arrived at in regard to the nerve-trunks. 
If a motor nerve of a frog be gradually heated up 
to 3o''-32° C. (Se^'-Sgl" F.), its irritability is pro- 
gressively increased, but at 35° or 36° C. (95^-96!^ 
F.) the excitability is abruptly lost. In mammals 
this loss of excitability occurs at 52° C. (l25|° F.). 
In birds, at 57.5° C. {i33}4'' F.). At precisely the 
degree at which in the different species of animals 
the irritability is lost there is also a molecular 
change in the nerve-substance, the myeline fusing 
so that the nerve-fibre becomes softer and more 
transparent, and its diameter greater. If a heated 
nerve be allowed to cool, it regains its functional 
power ; but on a second or third repetition of the 
heating, its functional ability is finally totally lost. 
My own experiments have not been directed so 
much to the close physiological study of the action 
of heat on nerve-trunks as to the answering of the 
question. Does the highest temperature reached in 
insolation affect seriously the conducting power of 
the nerves? They were made by exposing for sev- 
eral inches the sciatic nerve, passing underneath it 
a strip of india-rubber cloth, so as to isolate it 
from the muscles, and pouring water of a known 
temperature over it. At irregular intervals the 
conducting power of the nerve was tested by 
touching it with the poles of an induction battery 
above the heated portion. The animals were kept 
throughout in a state of complete anaesthesia. 



8o 



THERMIC FEVER, OR SUNSTROKE, 



The experiments were as follows : 
Experiment 17. — A young pup. 

LEFT NERVE. 
Time. Temp, of Water. Result. 

\ min. 140° F. Nerve transmits no impulse. 

5 " None applied. Has partially recovered its power. 



RIGHT NERVE. 

Result. 

No impairment of activity; in fact, nerve 
more excitable than normal. 

No impairment of activity. 

Nerve fails to transmit the strongest im- 
pulse. 

Nerve has not recovered itself. 



Time. 


Temp, of Water. 


6 min. 


120° F. 


I7i" 


120° F. 


5 " 


140° F. 



None. 



Experiment 18. — A young rabbit. Crural nerve em- 
ployed. 



Time, Temp, of Water. 



1 mm. 
2 
2 

2 ' 
2 ' 

3i' 



118° F. 
116° F. 
124° F. 
122° F. 
134° F. 
129° F. 
140° F. 
134° F. 



Rejnarks. 



Excitability of nerve seems increased. 



There is not yet any distinct impairment 
of conducting power of nerve. 



Experiment 19. — A large cat. 

Time. Teiiip. of Water. 

8 min. 120° F. 

4 " 130° F. 

5 " 124° F. 
5 '• 122° F. 
5 " 127° F. 
3 " 123° F. 



Remarks. 



No distinct impairment of conducting 
power of the nerve. 



NATURE. 8 1 

Experiment 20. — A very weak, sick cat. 

LEFT CRURAL NERVE. 

Time. Temp, of Water. Re-marks. 

5 min. 136° F. The nerve was not tested for five min- 

utes after heat was applied. The con- 
ducting power was then good, but 
somewhat lessened. 

3 " 134° F. Nerve transmits impulse only with diffi- 

culty. 

5 " None. Nerve has partially recovered itself. 

RIGHT CRURAL NERVE. 
Time. Temp, of Water. Remarks. 

6 min. 132° to 134° F. Some slight impairment of the conduct- 

ing power of the nerves. 

As far as they go, these experiments certainly 
confirm the statements of Henle and Pfeuffer, and 
demonstrate that the highest temperature ever 
reached in sunstroke is not sufficient to sensibly 
affect the conducting power of the nerves. 

Coma. — It is very evident from the experiments 
which have been detailed, that heat exerts a much 
more deadly influence upon the nerve-centres than 
upon the nerve-trunks, and that a temperature not 
higher than that reached in most cases of sun- 
stroke in man, not only induces symptoms similar 
in many respects to the nervous phenomena of 
insolation, but will also cause death by paralysis, 
from over-stimulation, of the respiratory centres. 
It becomes, therefore, a matter of grave interest to 
decide, if possible, what is the lowest degree of 



82 THERMIC FEVER, OR SUNSTROKE. 

heat which is sufficient to produce coma and con- 
vulsions. 

At first I was somewhat at a loss to invent an 
experiment which should settle the point. It is 
manifestly impossible to have the bulb of a regis- 
tering thermometer in the brain so as to mark the 
point at which convulsions come on. 

I finally determined, as the best method at my 
command, to apply the hot-water bonnet to the 
head of an animal, and immediately after the in- 
duction of decided nervous symptoms to open the 
skull and plunge a thermometer into the brain. 
When the coma comes on gradually, so that it is 
impossible to determine the time exactly when it 
commences, this method is very imperfect, but under 
favorable circumstances is sufficiently accurate. 

The following experiments were performed in 
this way, and I think the results yielded are 
sufficiently accurate for practical purposes : 

Experiment 21. — A full-grown cat.^ 

Remarks. 



Time. 


Temp, of Water. 


12. 


130° to 170° F. 




during the hour. 


I. 


140° F. 



Cat has been for some time very quiet, 
evidently semi-comatose ; at times 
arousing herself. Pupils moderately 
contracted. 
1. 15 180° F. Cat was so comatose that an attempt 

was made to open the head. The first 
incision was not noticed ; but the sec- 
ond aroused her. 



NATURE. 



83 



Tune. Temp, of Water. Remarks. 

1.30 180° F. The pupils have been strongly con- 

tracted, and cat quiet and semi-coma- 
tose. Suddenly pupils at once dilated 
widely, and a severe convulsion came 
on. This was so severe that I think 
the cat would have died in it. In the 
midst of the fit, however, the skull was 
opened and the thermometer plunged 
into the brain. It indicated 108° F. 

Experiment 22. — A young kitten. 

Time. Temp, of Water. Remarks. 

1.40 170° F. 

1.55 Kitten has been semi-comatose, with 

strongly contracted pupils, for some 
time. Suddenly its pupils dilated, 
and a general epileptiform convulsion, 
commencing in the muscles of the 
jaw, set in. In the midst of this the 
thermometer was plunged into the 
brain. It indicated 107^° F. 

For reasons before given, it seems irresistibly 
probable that if a temperature of 1 08 F. in the brain 
of a cat will produce these serious symptoms, it will 
induce no less in man. 

The conclusion is apparently unavoidable that 
the nervous symptoms of sunstroke may be, and 
probably are, due to the direct action of the heat 
upon the cerebro-spinal axis, and that death itself 
by asphyxia is often brought about by the same 
influence. 

The only objection of any force which I can 
imagine capable of being raised against the conclu- 



84 THERMIC FEVER, OR SUNSTROKE. 

sion just drawn from the previous experiments, is 
that the results were not really due to the imme- 
diate action of the heat, but to a determination of 
blood to the head and consequent congestion of the 
brain. 

The want of validity of this objection is appar- 
ently demonstrated by the following facts : 

1. Sudden epileptiform convulsion is not gen- 
erally the result of congestion of the brain. 

2. Opening the skull through the longitudinal 
sinus, although necessarily affording immediate 
relief of any existent congestion, did not stop the 
convulsion. 

3. Abstraction of the heat by the pouring of cold 
water over the head, sufficed to produce immediate 
cure. 

Dr. Richardson, of London, in a lecture pub- 
lished in The Medical Times and Gazette, takes a 
different view of sunstroke. He says, ^^ There is 
little difficulty in explaining the cause of the coma 
of sunstroke : it is due to the contraction of the ves- 
sels which supply the brain with blood, and to the 
subsequent changes in the nervous system incident 
to withdrawal of blood." 

Unfortunately, Dr. Richardson does not deem it 
necessary to prove this explanation, and it there- 
fore rests merely upon his ipse dixit. The experi- 
ments herein detailed certainly show that whatever 



NA TURK. 



85 



may be the immediate method through which it 
acts, high temperature within the brain causes the 
nervous phenomena, and to invoke the aid of the 
capillaries in explanation of this fact seems to me 
to be unnecessary, and, in the absence of proof, 
gratuitous. I think the more direct and therefore 
more logical supposition is, that the heat overstim- 
ulates the nerve-cells themselves. More than this, 
what little evidence there is points strongly towards 
the latter conclusion. It is impossible to believe 
that during the comatose stage of coup de soleil 
there is a state of general vaso-motor excitement, 
because in both animals and man the general, if not 
absolute, rule is, that during the coma the pupils 
are minutely contracted. This is equally true 
whether the applied heat be general or restricted to 
the encephalon. 

As a part of the convulsion, there is no doubt 
often vaso-motor spasm, with sudden, abrupt, wide 
dilatation of the pupil ; but all these appear to 
be secondary, not primary, phenomena, preceded, 
not followed, by changes in other nerve-centres 
than the vaso-motor. 

In order to prove that what is the possible and 
also probable cause of any effect is the absolute 
cause, it is often necessary to disprove other as- 
serted causes, and therefore the full establishment 
of the fact that heat is the real primary and imme- 
diate cause of the nervous disturbance of sun- 

8 



86 THERMIC FEVER, OR SUNSTROKE. 

stroke, must be put off until the pathology of the 
blood is considered. 

The Blood. — As has already been stated under the 
head of Pathology, the blood in sunstroke suffers 
very markedly. In man it is always black, or very 
dark, semi-fluid, with its alkalinity impaired, — in a 
word, presenting largely the appearances and con- 
ditioYis which exist in it in cases of low fevers. In 
my experiments in animals, it has partaken of these 
characters to a degree, but not so obviously as it 
appears to have done in the experience of Claude 
Bernard and Vallin. Both of these observers, 
struck by the dark color of the blood, have made 
researches as to its gases. 

The method which Claude Bernard employed 
was substantially as follows: By means of a syringe, 
blood was drawn from the vena cava of an animal 
just dead of sunstroke, and passed without expo- 
sure to the air into a glassreceiver, previously fitted 
to a mercury-pump. The gas, which was obtained 
from the blood by the latter, passed immediately 
into a graduated measure. It of course consisted 
of oxygen, nitrogen, and carbonic acid. The last 
having been absorbed by means of potash, and the 
first by the use of pyrogallic acid, what was left 
represented the nitrogen. From lOO cubic centi- 
metres of blood were obtained: 

Blood. loocc. 1^^2 37.2 ccentim. 
i O i.oo •" 



NATURE. 



87 



In a second experiment there was a momentary- 
exposure of blood to the air. The result was as 
follows : 

CO2 27.9 c. centim. 
Blood, 100 c. centim. O 3.8 " " 
N 9.4 " - 

Normal venous blood, treated in the same way, 
yields, according to Claude Bernard, from 12 to 15 
c. cent, of oxygen per 100. 

The analyses given by Vallin (p. 150) yielded 
the following results. Gas obtained in 100 volumes 
of venous blood : 

Normal Blood, Heat-Stroke^ Exp, x. Heat-Stroke^ Exp. 2. 

CO2 37-26 c. c. 36.79 c. c, 35-96 c, c, 

O 13.81 •• 0.94 " 0.75 " 

N 2.62 " 3.96 " 1.70 •* 



53.69 " 41.69 " 36.41 " 

After the addition of sulphuric acid to the blood : 



Normal Blood. 


Experiment i. 


Experiment 2. 


CO2 9-37 c.c. 


6.42 c. C. 


1. 51 c. C. 


1. 12 " 


0.57 '* 


0.38 " 


N 1.25 " 


3.21 '* 


0.38 " 



11.74 " 10.20 " 2,27 ** 

These analyses, having been made by different 
investigators, and being entirely in unison, and 
also in accordance with the pointings of all the 
other facts of the case, must, I believe, be accepted 
as demonstrating that after death of animals from 



88 THERMIC FEVER, OR SUNSTROKE. 

heat the proportional amount of oxygen in the 
blood is only a fractional part of what it normally 
should be, and that the dark color of the blood 
is largely owing to this absence of oxygen. 

The question which presents itself is, To what is 
this absence due ? That it is not due, as might be 
at first supposed, to such a destruction of the life 
of the blood as to prevent the absorption of oxygen, 
is shown by the fact that if the blood be drawn 
from the vein during life, or directly after death, and 
be shaken in the air, it rapidly assumes the arterial 
tint. Claude Bernard (loc. cit., p. 185) explains pov- 
erty in oxygen by stating that when blood has its 
temperature elevated it has a very great power of 
changing oxygen into carbonic acid, and that the 
phenomenon is really a post-mortem result; for if 
the ''body be opened instantly after death, and the 
arrest of the heart's action, the blood is still red in 
the arteries, especially in cases where death has 
been produced simply by the breathing of the hot 
air, the body of the animal remaining outside of the 
stove/* As to the latter class of cases I cannot 
speak, having had no experience. The conditions 
are so artificial, so unlike those of genuine sun- 
stroke, that it has not seemed necessary to make 
the experiment. I have, however, examined a 
number of cases of heat-stroke in animals, and in 
all of them the blood was everywhere dark, even 
when the animal was killed before the appearance 



NA TURE. 



89 



of any indications of immediate death. To me the 
explanation of the small quantity of oxygen in the 
blood in sunstroke, both before and after death, 
is very simple. Oxidation under the stimulus of 
the high temperature must go on with intense 
rapidity ; and, no doubt as a direct result of this, the 
respiration very early in the affection becomes im- 
mensely accelerated, and for a time this rapidity 
serves to maintain more or less fully the balance of 
demand and supply. But by-and-by the respira- 
tion begins to fail ; although no less rapid, it grows 
shallower and less perfect, and the constantly in- 
creasing demand is met by a constantly diminish- 
ing supply, until, in many cases, death results from 
gradual asphyxia, and long before life is extinct, 
the livid, purple surface, the dark, stagnant capilla- 
ries, indicate what is taking place. 

The fact that the red globules are generally able 
to absorb oxygen after death, would indicate that 
the blood has not lost its vitality : that it is not 
dead. 

This indication receives very strong corrobo- 
ration from the experiments of Max Schultze 
(Schultze's Archiv, i.), who found that when blood 
was heated in a moist chamber, under the micro- 
scope, no alteration took place in the red globules 
until a temperature of nearly 52° C. (125!° F.) was 
reached, when they became contracted and broke 
up into debris and little masses of coloring matter 

8* 



90 



THERMIC FEVER, OR SUNSTROKE, 



At a temperature of from 45° to 46'' C. (113'^- 
1 14I F.) the amoeboid movements of the white cor- 
puscles became more active, and continued so for 
a greater or less length of time. When the tem- 
perature was raised to 50° C. (122^ F.) they stiff- 
ened, as it were, retaining permanently the condi- 
tion or shape in which the heat found them. 

Eulenberg and Vohl, according to Vallin, have 
advanced the theory that death from sunstroke is 
the result of the sudden liberation of gases in the 
blood. According to both Hermann (Virchow's 
Archives, t. Ixii.) and Vallin (Archives Generales, 
Jan. 1872), the w^ork of these authors is a most re- 
markable mixture of all that is bad in scientific 
treatises. Vallin gives at some length the reasons 
of Eulenberg and Vohl, and, as their proofs do not 
amount to anything whatever, and the whole theory 
is very unreasonable, I am content to simply refer 
my readers to the reviews by Hermann and Vallin. 

A more plausible theory is one originally pro- 
posed by Weikard and recently supported by Dr. 
Richardson, of London. (St. Bartholomew Re- 
ports, vol. vii.) I have not seen the paper of the 
former of these authorities, but according to Vallin 
(Archives Generales, Jan. 1872), the memoir ap- 
peared in the "Archiv der Heilkunde," 1863, p. 
193, under the title of *' Versuche liber das Maxi- 
mum der Warme in Krankheiten." In this paper 
Weikard states that one of the dangers of high 



NATURE, 



91 



temperature is an augmentation of the coagulability 
of the blood and consequent formation of clots in 
the vessels. As quoted by Vallin, the principal 
proof brought forward is that the coagulation of 
blood occurs more rapidly outside of the body 
when it is heated than when cold. The following 
table expresses one of his experiments : 

123 

Man, 20 to 30 1 Commencement T, + 23° T. + 43° T. + 23° 

years old. \ of coagulation, i minute. Instantly. i minute. 

Apoplexy. j Firm coagulum, 20 " 12 minutes. 18 " 
Separation of 

serum, 12 ** 8 " 10 '• 

Diameter of clot 

after 2 hours, 34 cent. 33 cent. ? 

The result reached by Weikard was, that by a 
temperature of from 36° to 40° C. (96|^-i04°F.) 
the coagulation is retarded, below and above that 
it is accelerated. 

Dr. Richardson, of London, in the lecture in The 
Medical Times previously alluded to, expresses a 
similar belief He says, ''At this stage there may 
be slower motion, gradually falling temperature, 
and collapse. These changes indicate in nearly 
every instance that there has been separation of 
fibrine in the heart. The separation has stopped 
or arrested the current of the blood at the main, 
and virtually all is over. In the human subject 
we recognize by external signs this condition con- 



g2 THERMIC FEVER, OR SUNSTROKE. 

stantly ; in the inferior animals we produce it syn- 
thetically, and determine it with precision. 

'* Here, in illustration, is the dead body of a cat. 
In this animal there was, during life, an induced 
increment of heat or fever. The fever progressed 
until the mean temperature of the animal had 
reached an increment of nearly lO degrees; then 
the animal began to sink. She might have strug- 
gled on hopelessly for hours, as human bodies do; 
but we could in her case put her to death, in sleep, 
by making her inhale the vapor of ether. We did 
so, and at once laid bare the heart. See what has 
happened. The right cavities are almost filled with 
a firm separation of fibrine." 

Coagulation of the blood in the heart is certainly 
not a common occurrence in animals killed with 
heat. I have examined a large number of such 
hearts and have never seen any coagula. I have 
also examined all of the arteries of some cases, 
without finding thrombi. As will be shown here- 
after, if a pigeon be revived after having been 
nearly killed by heat, it recovers consciousness, but 
remains partially paralyzed, and finally dies. It oc- 
curred to me that possibly this might be due to 
coagulation of the blood in the small capillaries, 
and, to test the matter further, the following experi- 
ments were instituted : 

Experiment 23. — Two pigeons were killed by the hot box. 
Two hours afterwards their brains were carefully examined 



NATURE. 



93 



with the microscope. The capillaries Avere almost all of 
them empty ; a few contained masses of blood-corpuscles, 
none of them, however, firm clots. 

Experiment 24. — Pigeon was put in hot box, and when 
dying, its head was cut off. In the examination of the brain 
capillaries I failed to detect any thrombi. 

Experiment 25. — A pigeon was partially revived from 
heat-stroke, and its head then cut off. A careful microscopic 
study of the brain gave the same negative results as in the 
other cases. 

As the results of my experiments, I am forced 
to refuse assent to the idea that coagulation of the 
blood in the living body is a factor in the history 
of sunstroke, and to explain the single experimental 
result deduced by Richardson as due to the slow 
death of ansesthesia. Clinically viewed, the matter 
appears even more definite. Loss of coagulability 
of the blood is the one great lesion of human coup 
de soleil, to whose existence all observers bear wit- 
ness ; and in the absence of all evidence of real 
weight, it seems most illogical to conclude that death 
is ever due to the formation of coagula during life. 

In my experiments upon animals, I have never 
witnessed the profound breaking down of the blood 
often seen in human sunstroke. Other experiment- 
ers have had different experience ; and, after all, the 
difference is one of degree, not of kind. The ab- 
sence of these blood changes in many of the cases, 
especially in the most rapid and when the nervous 
symptoms are the most severe, shows that they are 



g4 THERMIC FEVER, OR SUNSTROKE. 

secondary, not primary, in their position. Indeed, 
the whole testimony of the facts which have been 
eHcited in regard to sunstroke is in accord with this 
view, for in rapid cases there is, as already stated, 
comparatively little deterioration of the blood. In 
slow cases, the vital fluid suffers the same degra- 
dation that is seen in other fevers with high tem- 
perature. When once these changes have been 
set up, it cannot be doubted that they react upon 
the nervous system, and possibly at times serve 
to keep up the disease. In human sunstroke, 
running a course mayhap of many hours or even 
days, the secretions are largely arrested, whilst tissue 
changes are vastly accelerated; more effete matter 
than normal is thus poured into the blood, and the 
avenues of discharge are choked up ; so that both 
directly and indirectly the vital fluid is degraded, 
until at last it in some cases no doubt becomes 
incapable of sustaining life. 

Before making a general review of the subject, 
it remains to establish the proposition already 
given, — that heat is not merely a possible and 
probable, but the absolute and only cause of the 
primary nervous symptoms of sunstroke. 

It is not requisite, after what has been said, to 
go much into detail, for it is an almost absolutely 
necessary conclusion from what has been demon- 
strated, that the changes in the blood are not the 



NATURE. 



95 



cause oi coup de soleiL It is, however, comfortable 
to have this conclusion experimentally verified. 

It has been shown that the life of the blood is not 
destroyed, and that there are no embolic arrests of 
circulation. There remains only the possible, but 
exceedingly improbable, supposition, that a specific 
poison is developed in the blood. Dr. Stiles (loc. 
cit.) has proven that the injection of the blood of 
an animal dead of heat-stroke into the veins of a 
second animal, is not productive of harm to the 
latter. Surely I am justified in believing that it 
has been shown that all possible causes (except 
heat) of the primary nervous disturbance have no 
real existence as such, and in asserting the truth of 
the proposition that abnormal temperature is the 
only poison present. 

If this be so, withdrawal of the heat before too 
much damage has been done, ought to be followed 
by immediate relief of the symptoms. The follow- 
ing experiments show that this is the case : 

Experiment 26. — A young rabbit was put in a glass box 
set in the sun ; in twenty minutes he was apparently totally 
unconscious, having passed through all the ordinary symp- 
toms. He was now taken out, and put in a bucket of water. 
The temperature of his body rapidly fell to normal, that of 
the water rising two degrees, and consciousness was re- 
stored at once. He was very weak, but in a few minutes 
was able to walk some, and the next day was as well as 
ever. 

Experiment 27. — A pigeon of full age, with anal temper- 
ature io8J°, was placed in hot box (130° F.) at 1 1 .42 a.m. At 



q6 thermic fever, or sunstroke. 

12 M. it had a convulsion, followed by persistent opisthotonos, 
with complete unconsciousness, which indeed had been 
nearly complete before the convulsion. 12.2 p.m. the pigeon 
was taken out, utterly unconscious, and at one time I thought 
it was dead : there were only a few gasps at long intervals. 
I plunged it into a tub of cold water, and kept it there. 
Its respirations slowly improved ; but after it had been in 
some three or four minutes it had a violent convulsion, after 
which for awhile it again appeared to be dead. It, how- 
ever, slowly got better again, and in about fifteen minutes 
was taken out of the water and put in the air. It was now 
perfectly conscious, and breathing slowly and regularly, 
but was not able to walk. In two or three minutes it was 
able to push itself rapidly forward with its feet, on its breast, 
but was unable to raise its body from the ground. Its anal 
temperature was 100°. It was now left in a basket at i p.m., 
apparently improving. At 2 p.m. it was found dead, still 
warm. I saw the body at 4 p.m. There was general rigidity, 
and the blood was not coagulated anywhere. 

Experiment 28. 

Tei7ip. A nal 

Tune, of box. Temp. Remarks. 

11.40 120° F. 105° F. __ 

11.48 120° F. 112° F. 

11.55 120° F. 117° F. The pigeon had previously struggled violently, 
but its struggles were apparently voluntary. 
It was so weak as not to be able to walk, 
and was now taken out of the box. It was 
unable to stand at all. 12.8 P.M. the anal 
temperature 112^°; pigeon is now able to 
push itself along, although not to stand. 
12.30 P.M. pigeon apparently all right, but 
not disposed to fly, and its feathers seem 
ruffled. Pigeon died some time between 2 
and 5 P.M. Autopsy made twenty-four 
hours afterwards showed that the blood was 
fluid, and very dark. 



NA TURE. 



97 



Experiment 29. — Adultpigeon. Anal temperature, 109^°. 
At 12.29 P.M. it was put in hot air chamber. 12.39 P-M., anal 
temperature, 112°. 12.53 p.m., anal temperature, 117^°. Bird 
lying on back and side, apparently dying. It was plunged 
in cold Avater for several minutes, and when taken out its 
anal temperature was 109^°. It was unable to make any 
effort; with very irregular, jerking breathing, so that I mo- 
mentarily expected it to die. It was not again put in water. 

2 minutes (after taking out of water). — Temperature, 107°. 

3 minutes. — General condition growing worse. 

10 minutes. — Reviving. Able to push itself along. 

12 minutes. — Temperature, ioiJ°. On application of gal- 
vanic current, muscles respond well. 

25 minutes. — Although pigeon has been in a warm place, 
its temperature is 96°. 

2 hours. — Pigeon much better; lies quiet all the time, but 
can walk, though constantly falling ; still, is better. It has 
been dry and in a warm place for two hours, but its temper- 
ature is only 100°. 

3 hours. — Left as before. 

5 hours. — Found dead, cold and rigid. Blood as first 
taken out dark and fluid, but on standing in a test-tube 
forming into a firm coagulum. 

These experiments certainly demonstrated what 
has been claimed. The after-death of the pigeons 
is probably explainable as the result of permanent 
damages done to the nervous system, due to the 
intense heat. 

Theory of Disease. — Sufficient progress has now 
been made in this memoir to render necessary a 
short review of the facts that have been developed, 
preparatory to a final sketch of the nature of coup 

9 



q8 thermic fever, or sunstroke, 

de soleil. It will be called to mind by my readers, 
no doubt, that it has been shown that the sole efifi- 
cient, always present, cause of sunstroke is excess 
of temperature ; that whilst circumstances of the 
degree of moisture in the air, or of the condition 
of the patient, as race, acclimatization, temperance, 
health, and so forth, have great influence, yet they 
possess such influence only in so far that they 
render the heat more penetrating or efficient, on the 
one hand, or the patient less capable of resisting the 
heat by the natural methods of self-cooling, on the 
other; that the disease is generallyprecededbymore 
or less marked prodromes, and that when it is fully 
developed the symptoms consist simply of intense 
fever, with great nervous disturbance, as shown by 
unconsciousness, paralysis, convulsions, etc., and 
that in most cases death results from gradual 
asphyxia or a simultaneous failure of circulation 
and respiration ; that there are cases whose course 
is almost like that of lightning -stroke, — instant 
death, — the patient suddenly falling forward in a 
condition of fatal syncope, and that these cases al- 
ways occur during active exercise ; that the most 
obvious lesions found after death are, a condition 
of the blood similar to that seen in low fevers, and 
great rigidity of the heart. 

In the second or experimental portion of the 
memoir it was shown, — 

That sunstroke may be produced in animals as 



NA TURK, gg 

readily as in man, either by natural or artificial 
heat; that the symptoms are similar to those seen 
in man ; that death takes place ordinarily by as- 
phyxia ; that after death the characteristic lesions 
are alteration of the blood and rigidity of the heart, 
with immediate or quickly appearing post-mortem 
rigidity of the general muscular system ; that this 
rigidity of the heart comes on in most cases after^ 
not before, death, and is a result, not cause, of 
death ; that post-mortem rigidity is dependent 
upon coagulation of myosin, and that the rigid- 
ity of the heart is of similar origin, coagulation of 
the muscle plasma occurring almost instantane- 
ously at 115° F., a degree almost attained in sun- 
stroke; that when a muscle has been in great 
activity immediately before death, the myosin co- 
agulates at a much lower temperature, and that 
the cases of sudden cardiac death occurring in bat- 
tle among the East Indian English troops were no 
doubt due to the coagulation of the heart's myo- 
sin ; that heating the brain of a mammal produces 
sudden insensibility, with or without convulsions, at 
a temperature of 108° F., and death when a tem- 
perature of 113° F. is reached; that this effect 
of the local application of heat is not due to in- 
duced congestion, but is the result of the direct 
action of the heat upon the cerebrum, and that 
consequently the nerve-centres are as perniciously 
affected by high temperature as the muscles are; 



100 THERMIC FEVER, OR SUNSTROKE. 

that the nerve-trunks bear a temperature of 125° 
F. without their conducting power being imme- 
diately affected ; that whilst the general symp- 
toms induced by heating the brain of a rabbit are 
very different from those of sunstroke, the nervous 
symptoms are exactly similar; that the life of the 
blood is not destroyed by any temperature reached 
in sunstroke, the amoeboid movements of the white 
blood cells and the absorption power of the red 
disks not being injured ; that the amount of oxygen 
of the blood is greatly lessened, as the result of 
gradual asphyxia combined with abnormal con- 
sumption of oxygen; that there is no reason for 
believing that capillary thrombi are common in sun- 
stroke ; that there is no specific poison developed 
in the blood; that the deterioration of the vital 
fluid is due to the rapid tissue changes induced by 
the fever, and the more or less complete arrest of 
excretion ; that such deterioration is secondary^to 
the nervous symptoms, not primary ; that if the 
heat be withdrawn before it has produced perma- 
nent injury to the nervous system, blood, or other 
tissues, the convulsions and unconsciousness are 
immediately relieved, and the animal recovers. 

As a postulate from these facts and deductions, I 
think it follows that the nature of sunstroke is that of a 
fever ^ or, in other words, that coup de soleilis a fever ^ 
not dependent upon blood-poisonings but upon heat, — an 
ephemeral or irritative fever, if the term be preferred. 



NATURE. jQI 

It is well known that certain lesions of the 
nerve-centres will cause fever without the super- 
vention of inflammation or blood-poisoning ; such 
a lesion is section of the spinal cord in the neck. 
Indeed, it is apparently inconceivable that inflam- 
mation itself can cause fever in any other way 
than by a reflex action upon the nervous system. 
Further, every practitioner has seen fever, and 
even ''the fevers," produced or developed largely 
through the nervous system. Very recently I 
have had a patient convalescent from severe ty- 
phoid fever, in whom the temperature for a week 
had not been over 99° F. She, contrary to orders, 
got out of bed, and made considerable exertion, 
and within fifteen minutes had a slight rigor, fol- 
lowed by intense fever, the temperature rising at 
once to 104°, and in a few hours to 107° F. At 
the same time, grave nervous symptoms were de- 
veloped, and the pulse rose above 150, so rapid 
and thready that it could not be counted. There 
are two explanations of these facts, either of which 
is conformable to our present knowledge : 

First. That fever depends simply upon paralysis 
of the vaso-motor nerves. 

Second. That there is in the medulla or higher 
up a controlling centre, which influences through 
the vaso-motor or other nerves the heat production 
in the body. 

Which of these be the truth it is not necessary 

9* 



I02 THERMIC FEVER, OR SUNSTROKE. 

for our purpose to be determined, the theory of 
sunstroke being plain in either case. When a 
man is exposed to heat beyond his powers of re- 
sistance, there is a gradual slow rise of temper- 
ature, until the stimulus of the heat becomes so 
intense as to paralyze either the heat centre or the 
vaso-motor nerves, as the case may be, and then 
there is probably a sudden intensifying of the oxi- 
dation processes, and a further rise in temperature, 
preceded, accompanied, or followed by an over- 
whelming of the cerebrum; in other words, intense 
fever, with its accompaniments, is developed. 

That sunstroke is of the nature of a fever was 
dimly seen by Sir J. Randall Martin and other 
Indian writers, but not distinctly postulated by 
them, at least that I know of, and the standard 
authorities of England to-day do not consider sun- 
stroke among the fevers. 

It is said that Dr. Gerhard formerly taught in 
his clinical lectures that sunstroke is a fever; but I 
am not aware that he has put such opinion on 
record 

In a paper in the American Journal of the Medical 
Sciences, Jan. 1859, Dr. J. J. Levick makes an elab- 
orate comparison between the post-mortem results 
of typhus fever and sunstroke, and says, " These 
facts would seem to indicate that there is in sun- 
stroke, as there is in typhus fever, a poisoned con- 
dition of the blood, and that it is to this that we 



NA TURE. 



103 



are to refer the various morbid phenomena of the 
disease. I cannot, however, divest my mind of the 
behef that in sunstroke this unnatural condition of 
the blood is a secondary affection, not the primary 
one ; that there is, in the first place, an exhaustion 
or depression of the nerve-forces which regulate 
nutrition, respiration, circulation, and the other 
acts of organic life." 

In 1863 I published a paper in the American 
Journal of the Medical Sciences, in which I insisted 
strongly upon the claim of this disease for a place 
among the fevers, and gave it a name as such, 
namely. The nnic Fever. I believed at that time that 
the nervous symptoms were due to the development 
of a poison in the blood, not perceiving that the 
heat itself was the poison. 

In the last edition of his Practice of Medicine, Dr. 
George B. Wood allowed the claim of sunstroke 
for a place among the fevers. He says, '' Heat is 
a universal stimulant to the organs ; and excessive 
stimulation, or rather the high degree of irritation 
that attends it, has a tendency first to derange, and 
in the end to diminish or suspend, the functions of 
these organs." In accordance with these views, Dr. 
George B.Wood proposed the name oi Heat Fever 
for the disease. Since the difference between the 
two names seems to be very slight, I have retained 
Thermic Fever, as having the priority. 



PART III. 

TREATMENT. 



The treatment of sunstroke has been very various 
in the past, just as the ideas as to the nature of the 
affection have been so diverse. By the first observ- 
ers it was looked upon as the result of rush of blood 
to the head, and the quick, often full and hard pulse, 
the hot skin, suffused face and eyes, the sudden 
unconsciousness, the convulsive startings, all seemed 
to them to call most imperatively for bleeding. Ac- 
cordingly, they practiced venesection, and for a time 
believed they derived advantage from it; but the 
frightful mortality which attended this practice 
soon forced the abandonment of the lancet, and 
latterly venesection appears to be condemned as a 
general practice both by American and Indian sur- 
geons, the testimony of some of whom I subjoin. 

Dr. Dow^ler, of New Orleans, has occasionally 

seen bleeding apparently do good, yet, as a general 

measure, he unqualifiedly condemns it. He says 

(New York Medical Gazette, 1842), '* Doiring the 

( T04) 



TREA TMENT. 



105 



last five years I have been called to see a very con- 
siderable number of sunstruck persons, within five 
or ten minutes after they fell in the streets. For- 
merly, I used to bleed them, and though the great 
heat of the body is thereby suddenly diminished, 
the pulse becoming soft as air, yet by the time the 
arm is tied up (which is done for form more than 
for necessity), the patient is suddenly choked, and, 
to appearance, by a dense tenacious mucus, the 
breathing not ceasing gradually, as in other dis- 
eases, but instantly, the face turning livid, and even 
its veins, especially upon the forehead, becoming 
at the moment distended. Bleeding hastens the 
strangulation, though it is always desired by 
friends." 

Dr. Swift (New York Medical Journal, 1854) con- 
demns bleeding, and also the indiscriminate use of 
affusions. Looking on the cases as instances of cold 
collapse, he advises that the patient be put in a hot 
bath, rendered stimulant by capsicum or mustard, 
and that general stimulation be used. 

Surgeon Thos. Longmore, of the Indian army 
(London Lancet, 1859), condemns venesection, ex- 
cept in rare cases, and extols cold affusions, with 
purgative enemata, and mustard-plasters along the 
spine. 

Dr. Wm. Pirrie, of the same service, says, '* I 
have been told by many who had had ample 
means of observation, that venesection always 



T06 THERMIC FEVER, OR SUNSTROKE. 

seemed to hasten a fatal termination." He com- 
mends cold affusions to head and chest, with dili- 
gent use of frictions and heat to legs and arms. 

Crawford says (The Madras Quarterly, Oct. 
i860, p. 330), ''I have never seen any advantages 
derived from venesection in such cases, and I am 
satisfied that the reverse is often the case. It is 
worthy of remark that its strongest advocates 
admit 'that blood-letting kills, if it does not cure 
the disease,' and that * to deplete with good re- 
quires care and discrimination, aided by a calm 
judgment.' " 

Dr. G. S. Beatson (Med. Times and Gazette, Dec. 
1857) condemns bleeding very strongly. He states 
that, in an epidemic which he witnessed, four cases 
were treated by venesection, with three deaths, 
whilst of eight cases treated by repeated cold affu- 
sions to head, chest, and epigastrium, all recovered. 

Dr. A. E. L. Longhurst (Lancet, Jan. 1869) com- 
mends treatment by pouring cold water freely on 
the head, and the internal use of croton oil in small 
quantity, with the free administration of brandy. 
He gives three cases, all of which recovered under 
this treatment. He believes the cold water to act 
by exciting the nervous system, and states that in 
his cases the immediate effects were raising of the 
pulse and forcible contractions of the voluntary 
muscles ; but if the douche were continued too 
long at one tim.e, it was followed by diminution of 



TREA TMENT. 



107 



the volume of the pulse and marked depression. 
He condemns venesection. 

Mr. J. R. Taylor, Deputy-Inspector of Hospitals, 
India, says, after describing a severe epidemic of 
the disease, " Had I fortunately before the epi- 
demic at Gozupore, 1843, ^^^ with the records to 
which I have referred, I should have been more 
moderate in the employment of venesection." He 
then speaks of an epidemic which he witnessed in 
1852, in which ''numerous" severe cases were 
treated simply by continuous cold affusions with- 
out one death. 

Further testimony might be adduced as to the 
impropriety of bleeding in sunstroke ; yet it can- 
not be gainsaid that occasionally whilst the blood 
has been flowing the patient has become conscious. 
Dr. Dowler appears to admit this freely, although 
condemning venesection. The truth appears to be 
that whilst, in some cases, blood-letting may do 
good, in by far the majority of instances it does 
absolute harm. There can be no doubt of the great 
refrigerating power of bleeding. Dr. Dowler ex- 
pressly states that the skin grows cool when it is 
practiced in coup de soleil^ I conceive that when 

* Since this memoir has gone to press, on re-reading Dr. Wm. 
Pepper's account of sunstroke (referred to in the early part of this 
work), I find that all his cases had been freely bled before he saw 
them. The cases were very probably true sunstroke, not simply 
heat-exhaustion, as I have suggested, and the cool skin was the 



I08 THERMIC FEVER, OR SUNSTROKE. 

venesection does good, it does so generally, if not 
always, by reducing the temperature ; and since 
other simpler and infinitely less exhaustive means 
of doing the same thing are so available, bleeding 
is generally exceedingly bad practice, even if the 
patient does recover. 

In order, however, to allow the other side of the 
question to appear somewhat, I append the follow- 
ing from a report in the Medical Times and Gazette ^ 
October, 1870 : 

Case XI. — Dr. J. H. Salter was called to a lad 16 years 
of age, who before the attack had been in perfect health. 
Dr. Salter, on arriving half an hour after the lad fell, found 
him "insensible, and wriggling in convulsions like an eel." 

He says, "The muscles of the trunk, neck, and legs were 
rigid, the countenance suffused, the eye directed backwards 
and fixed, the breathing snatchy and stertorous. 

"On closer examination, I discovered the pupils were 
contracted to a minimum, the conjunctivae were injected, 
and the teeth were firmly clinched together. The temper- 
ature of the body was abnormally high, with the surface 
dry and rough. The heart beat tumultuously, and the 
throbbing of the carotid was very energetic. 

"At the wrist the character of the pulse was small, quick, 
sharp, and wiry ; there was a lack of volume, not of pro- 
pelling force. I watched him carefully for some minutes, 
and his symptoms increased in severity, so that I considered 
him in extremis. I then took several ounces of blood from 

result of the bleeding. The soft, flaccid hearts were found because, 
the temperature not being high at the time of death, the cardiac 
myosin did not coagulate. 



TREATMENT. lOg 

his arm without delay. The effect was most striking. The 
convulsions were quickly relieved, and gradually ceased as 
the blood continued to flow ; the pulse became slower and 
fuller, the breathing less labored and snatchy, and the 
venous congestion of the face subsided ; the pupils relaxed 
a little, and by the time I had bound up his arm he lay in 
a heavy, oppressed sleep. 

" He was then removed to a neighboring house and put 
into bed. Cold applications were used to his head, and his 
extremities, which were now hot, were artificially warmed. 
^A dose of castor oil was given as soon as he could swallow, 
and through the night small quantities of weak beef-tea and 
brandy. 

"The next day the patient was much better and partially 
conscious. The following day he was able to be taken 
home." 

In remarking on the case, Dr. Salter says, " The 
immediate effect seemed to be to relieve the gen- 
eral venous congestion; to render the breathing 
calmer and less labored; to diminish the frequency 
and alter the character of the pulse ; to lessen the 
spasms and arrest the convulsions." 

The Indian treatment of sunstroke appears to 
be almost uniform of recent years, having the cold 
douche for its basis. Barclay, Aiken, Maclean, 
Morehead, Avary, and others, might be cited, but 
further quotation seems scarcely necessary, and 
would be cumbersome. At the same time, whilst 
experience has taught the Indian surgeons the 
value of the cold douche, it appears evident that 
most of them consider that it acts chiefly by rousing 

lO 



no THERMIC FEVER, OR SUNSTROKE. 

up the nerve-centres : a false theory, which must 
impair in practice the efficiency of the employment 
of the remedy. 

In America, no such uniformity of treatment has 
as yet prevailed, although in the last five years the 
drift of the professional teaching seems to be more 
in that direction. 

In 1859 (American Journal of the Medical Sci- 
ences, vol. xxxvii. p. 55), Dr. B. Darrach recom- 
mended that ice be applied to the skin, and also 
rubbings with ice, in sunstroke; and this treatment 
has subsequently been employed quite largely and 
been generally approved, especially by Dr. Levick 
(Pennsylv. Hospital Reports, 1868). 

In the same Reports for 1869, Dr. Jas. H. Hut- 
chinson details a number of cases in which hypo- 
dermic injections of morphia were employed. Six- 
teen were so treated, and all recovered but four: 
a result which certainly is much better than my 
own experience in the same hospital. At the same 
time, it is to be noted that in most or many of these 
cases the '' ice treatment" was more or less effi- 
ciently employed, so that the results cannot fairly 
be attributed solely to the morphia. 

It wull be noted that I have avoided making any 
statistical comparisons of results of treatment. I 
have done this from the belief that such inquiry 
would be worse than useless. The condition of 
the patient before the attack, the severity and form 



TREA TMENT. I j j 

of the latter, and the time at which treatment is 
begun, are so rarely noted, and are so diverse and 
so important in affecting the results, that all statis- 
tical comparisons seem futile. 

In concluding this essay, the final, practical 
question is, What is the best method of treating 
J sunstroke ? And I shall now attempt the answer 
of this. 

If there be any truth in the views of the nature 
of thermic fever taken in this memoir, it is self- 
evident that the chief indication in every case is 
the abstraction of heat. An excess of the latter 
agent is the materies morbi ; and if it can be re- 
moved before too much harm has been wrought, 
the patient will assuredly recover.' 

As soon, therefore, as a man falls, he should be 
carried into the shade with the least possible delay, 
his clothing removed, and cold affusions over the 
chest and body practiced. This must not be done 
timidly or grudgingly, but most freely. In many 
cases the best resort will be the neighboring pump. 
In the hospital, probably, a better method of re- 
ducing temperature than the cold affusion is to 
place the patient in the cold bath (50° F.), or rub- 
bings with ice may be practiced, and, as originally 
suggested by Dr. Parkes, enemata of ice-water may 
be given. 

In using these various measures, it must always 
be borne in mind that the indication is the reduc- 



112 THERMIC FEVER, OR SUNSTROKE. 

tion of temperature : if the means employed do 
not accomplish this, they do no good. 

Relaxation of the pupil is said to be ''the first 
symptom that shows the good of the cold affusion" 
(Aitken, Practice of Medicine, vol. ii. p. 394); but 
as, in my experience, the pupil frequently has not 
been contracted, too much reliance cannot be 
placed upon this; and I think the thermometer in 
the axilla, or better the rectum, affords the best 
guide as to the effect of the treatment. 

After the temperature has been reduced, and 
even after consciousness has returned, there is 
often a great tendency to a fresh rise of tempera- 
ture and consequent relapse. This tendency may 
be met by wrappings in wet sheets, and, if neces- 
sary, by a recourse to the more powerful measures 
for reduction of temperature, which have been 
already cited. 

It must be borne in mind, however, that the 
cold douche, cold battling, etc. are powerful rem- 
edies, and are capable, if used too long, of doing 
harm. 

In my experiments upon animals, I have seen 
the temperature, when once reduced by them after 
sunstroke, continue, notwithstanding their with- 
drawal, to fall until it w^as many degrees below 
normal. It needs no argument to establish the 
harmfulness of such reduction, and, whilst the possi- 
bility of its occurrence should not intimidate us in 



TREATMENT, II3 

the use of the measures, it should temper our bold- 
ness with caution. 

The evidence adduced by Dr. Hutchinson in 
favor of the hypodermic use of morphia, as first 
suggested by Dr. Herbert Norris, is certainly suffi- 
cient to justify its further trial. 

Dr. Hutchinson has stated to me, in conversation, 
that the effects of the remedy were most apparent 
in 'the convulsive form of the affection, and that, 
indeed, the power which it exhibited in allaying 
the spasms was most surprising. 

Moreover, theory seems rather to favor than dis- 
favor the practice, as it has been shown by Prof 
Binz that morphia has the power of checking 
tissue changes, and thereby lowering the tempera- 
ture. It seems impossible that the moderate use 
of morphia can do harm : it may do great good ; 
and I would, therefore, advise the hypodermic in- 
jection of a quarter of a grain of the sulphate every 
four to six hours, especially in the convulsive cases. 

After the first violence of the attack has been 
subdued, a blister may- be applied, as recom- 
mended by some English authorities. Aitken says 
(loc. cit, p. 394), '' The hair is to be cut short so soon 
as possible, and a blister applied to the nape of the 
neck, the surface having previously been first well 
^^ovi^^AW\\}i\ acetuvilyttce: . . . increasing confi- 
dence as to the ultimate result may be indulged in 
so soon as vesication takes place ; and, in cases 

10* 



114 THERMIC FEVER, OR SUNSTROKE. 

where insensibility recurs, after an interval of ten 
or twelve hours it may be removed by the applica- 
tion of a second blister to the vertex." 

While I would personally use a blister in this 
way, from deference to authority and in the hope 
it might do good, I would not rely too much 
upon it. 

Many of the Indian authorities advise a mild 
purgative; in most of the cases that I have seen, 
there was already diarrhoea; a dose of Rochelle 
salt would, however, do no harm, but in bad cases 
could hardly be swallowed early enough to do 
much good. 

Both Drs. Barclay and Maclean speak of a class 
of cases in which every attempt to administer the 
cold douche produces such violent convulsions 
that it is inadmissible. It seems probable that the 
cold baths, or rubbings with ice, would be borne 
by some of these cases; if so, they no doubt would 
be of inestimable value. 

The authorities alluded to have never tried these 
measures, but have used chloroform by inhalation. 

Dr. Maclean says, " In India I have saved the 
lives of many by acting on this advice" {i.e. giving 
chloroform). Dr. Barclay, in like manner, found 
chloroform useful ''in the convulsive form of the 
disease attended with extreme nervous irritability : 
... in some instances life was saved by the 
remedy ; in all it was prolonged." 



TREATMENT. 



IIS 



As alread}^ stated, it is especially in these cases 
that Dr. Hutchinson has found the hypodermic 
use of morphia of service. The best treatment of 
the convulsive form of the affection would, there- 
fore, seem to consist in the use of morphia and 
chloroform, with the cold bath, or ice rubbings ; the 
latter measures being practiced, if necessary, whilst 
the patient is in a state of anaesthesia, 



PART IV. 



SEQUELS. 



It* is a piiori very improbable that an affection 
which produces so rude a shock to the nervous 
system as does thermic fever, should not frequently 
be followed by grave after-effects. 

Experience confirms such probabilities, for in 
many cases, after recovery from the acute disease, 
various symptoms of deranged innervation mani- 
fest themselves. 

Comparatively little has been written upon the 
sequelae of the affection, but among Indian authori- 
ties, Maclean states that the least serious of these 
after-effects is " incapacity for service in India, or 
any hot climate, without at least a more or less 
prolonged stay in a cold climate." This inability 
to endure heat in some degree almost universally 

* This portion of the monograph has been added since the 
Boylston prize was awarded. 

("6) 



SEQUELAl, y\J 

follows sunstroke. It generally, with care, wears 
off, sometimes in a year or so, sometimes not till 
after a period of years. 

Persistent headache, very severe and very in- 
tractable, is spoken of by Maclean as a more 
serious sequela. 

Whilst serving in our army hospitals during the 
rebellion, I saw quite a number of men who had 
been disabled from duty by coup de soleil, and this 
cephalalgia, often associated with giddiness, was 
a very common, almost universal, symptom. 

Unfortunately, I kept no notes of cases ; but, 
through the kindness of Dr. Harrison Allen, I am 
allowed to publish the following brief notes, taken 
by him during his service. From the fact that the 
hospitals he had charge of were well towards the 
front, but few of such chronic cases remained for 
any length of time under his care, so that complete 
clinical histories were not obtainable ; but the ab- 
stracts given are sufficient to show the general 
symptoms. 

Case XII. — Wm. L. received a sunstroke May 6, 1864, 
during the battle of the Wilderness. Lay unconscious one 
hour and a half On recovery, had severe headache, and 
has suffered from it very much since. He had, previous to 
the attack, convergent strabismus of left eye, which has been 
much worse since. He also lost the sight of the eye at the 
time of the accident. Jan. 186$, he had his first convulsion ; 
has had three altogether. 

Tongue at present furred; pulse small, thready; sleeps 



Il8 THERMIC FEVER, OR SUNSTROKE. 

well ; bowels not costive. He suffers from persistent frontal 
headache. 

Case XIII. — David L. received a sunstroke in July, 1862, 
which was followed by drowsiness, headache, and vertigo. 
He was ill for several months. Up to present time, July, 
1863, has not been able to do duty. 

At present time is anaemic, with a calm pulse of 72, a clean 
tongue, slight epigastric tenderness, and some dyspeptic 
symptoms ; bowels regular. There is loss of memory, and 
at intervals there are attacks of vertigo and weakness, last- 
ing several days. 

Case XIV. — George W. Sunstroke one year ago. Before 
this time the patient had never had headache. Since the 
occurrence has had it constantly. There is marked loss of 
memory. Bowels constipated. Has attacks of vertigo and 
weakness on taking even gentle exercise. Exposure to sun 
produces intense headache and vertigo. He sleeps but very 
poorly. Mouth temperature 99° F. Pulse 95. 

Case XV. — B. L., about a year since, during a march 
after the battle of Gettysburg, fell senseless, and remained 
unconscious one hour. Since this he has suffered from 
constant intense headache and obstinate constipation. The 
bowels are never moved except by the aid of medicine. He 
sleeps poorly, and suffers from decided loss of memory. 
Exposure to the sun increases the headache very greatly. 
Reading causes dizziness and great pain in the eyes. Pulse 
95. Exercise produces great palpitation of the heart. 

Intense, fixed headache, with or without other 
serious indications of brain lesions, is often the most 
prominent symptom in these cases. The fixedness 
and obstinacy of the pain would seem to indicate 



SEQUELM. IIQ 

that it is more than functional, an indication con- 
firmed by the frequency with which other and 
more serious symptoms of brain-trouble are finally 
manifested. Thus, Dr. Pepper, in the paper previ- 
ously quoted, states that out of twenty cases treated 
in the Pennsylvania Hospital, three of the ten re- 
coveries resulted in chronic brain diseases, eventu- 
ating in insanity. 

In order to treat these cases intelligently, it is of 
very grave importance to decide what is the real 
nature of the trouble. 

Some time since, Dr. S. Weir Mitchell expressed, 
in conversation, the belief that in many, if not all, 
of the serious cases the after-lesion of thermic 
fever is meningitis ; and reflection has convinced 
me of the truth of his position. 

There can be no doubt that in many cases of 
sunstroke, after the subsidence of the original dis- 
ease, there is manifested a marked tendency towards 
the development of inflammation of the meninges 
of the brain. This has been noticed by several 
observers : thus, Bonnyman (Edinb. Medical Jour- 
nal, 1864) speaks of reaction sometimes setting in 
strongly, and requiring the application of leeches 
to the temples. 

Some years since. Dr. Mitchell, after walking 
about the city for nearly the whole of an intensely 
hot August day in the sun, went out of town a few 



I20 THERMIC FEVER, OR SUNSTROKE. 

miles, and climbed a steep hill in the intense blaze 
of the afternoon sun. At this time his carotids 
were throbbing tremendously, and he had an in- 
tense, bursting headache. He sat down to dinner 
a few moments after this, and shortly fell forward 
upon the table, entirely unconscious. 

He says that he has a dim remembrance of being 
helped up-stairs ; but beyond this is an absolute 
blank, in his memory, of ten days. During this 
period he is said to have had an intense fever, with 
delirious unconsciousness, and a rapid, feeble pulse. 

He was treated with cold applications, and at 
the end of the period named, after a prolonged 
mustard foot-bath, recovered his consciousness. 

The first sensation was that of an intense, agoniz- 
ing headache, and the next was the perception of 
his father— Dr. J. K. Mitchell— and Dr. Mutter dis- 
cussing the possibility of his recovery. 

As soon as he could speak, he said, " Bleed me.'* 
His father, coming to the bed, shook his head; but 
the son repeated, "' Bleed me." He persisted in 
simply repeating this, until they thought him de- 
lirious ; but at last he mustered strength to say, 
*' I am not delirious, but have a frightful headache: 
if you don't bleed me I will die." By this time his 
pulse had become full and bounding, and finally he 
sat up and was bled. Ten or fifteen ounces were 
taken without avail; but as more blood flowed the 
headache vanished, to be succeeded by a feeling of 



SEQUELy^. 121 

most delightful languor and rest from pain. Be- 
tween twenty-five and thirty ounces were taken, 
and afterwards recovery was a very simple matter. 
That Dr. Mitchell, by the bleeding, was saved 
from meningitis appears most probable, especially 
in the light of the following case, reported by Dr. 
J. J. Levick in the Transactions of the College of 
Physicians of Philadelphia : 

Case XVI. — A lad, aet. 17, had been engaged during the 
morning in unloading coal at a wharf in New York. While 
doing so, he complained of pain in the head, and fell over 
in a convulsion. He remained in a state of stupor, and 
was brought to Trenton in the canal-boat, unprotected, 
and thence by railway to Philadelphia. 

At the time of his admission he was in a semi-stupid state, 
but could be roused with some exertion. He had at that 
time ptosis of the right eye, with occasional delirium and 
other symptoms of inflammation of the brain, for which 
latter affection he was put upon the use of calomel, in small 
and repeated doses, blisters to the nape of the neck, etc. 
After death there was found extensive inflammation at the 
base of the brain. 

Dr. S. Weir Mitchell has generously allow^ed 
me to publish the following cases, which have oc- 
curred in his practice. They are strongly corrob- 
orative of the opinion already advanced as to the 
nature of the sequelae of sunstroke. 

Case XVH. — G. B., aet. about 35, ordinary seaman ; previ- 
ously well ; no syphilis. Being in the United States navy, 

I T 



122 THERMIC FEVER, OR SUNSTROKE. 

he was exposed to prolonged sun-heat on the African coast, 
while on some duty connected with overseeing a party of 
natives who were watering the ship. He came on board 
suffering from headache, which grew worse in the hot tropic 
night. The next day he fell on the deck, and soon became 
insensible. He thinks he was treated with purgatives, and 
cold to the head, but can recall little of what passed during 
three weeks, when he became well enough to be on deck. 
He was told that he had had sunstroke, and not the coast 
fever. Save rare headaches, he had no permanent evil re- 
sults, but the least exposure to sun made him suffer with 
parietal pain and with weakness. Two years later, in Nor- 
folk, a long exposure to heat produced general feebleness 
and headache, which lasted a month or more. Thencefor- 
ward his headaches were frequent and severe in summer, 
but less common and more mild in cold weather. He en- 
tered my wards at St. Joseph's Hospital two years after his 
last stroke, and had then great general weakness and con- 
stant headache, with buzzing in the left ear. As well as I 
remember, the senses were otherwise unaffected, and the 
lungs, heart, and kidneys healthy. There was, however, 
slight acid dyspepsia, and intense constipation. A great 
variety of treatment had failed to relieve his pain, which 
was severe, was worst during the day, and was only eased 
by heavy doses of opiates. A few days after he entered, he 
became sluggish and inattentive. This was followed by 
lessened complaints of headache, and somewhat later by 
stiffness in the muscles at the back of the neck, with con- 
tracted pupils, coma, and death. On examination we found 
a remarkably extensive meningitis, some of it old, and some 
new. The later trouble lay chiefly at the base, and there 
was no other brain lesion proper. 

The following case seen very recently offers 
many points of likeness to that just related : 



SEQUELS, 123 

Case XVIII. — Mr. , United States army, a sturdy, 

well-made man, set. 30, married four years, but childless, was 
in perfect health until August, 1869, when serving in Texas 
he contracted ague, which proved very persistent. While 
still liable to rare attacks of this disease, he was called upon 
to ride a long distance in a very hot sun. On his return he 
dismounted, and, while standing by his tent, he began to 
feel headache, very suddenly. In addition to this he had 
true vertigo, external objects turning around him, and vio- 
lent throbbing of the head, especially behind his ears, and 
also in the arteries of the neck. His face was deeply flushed, 
and I presume from his statement that he must have felt just 
such symptoms as follow a full inhalation of nitrite of amyl. 
He staggered into his tent, and lay down, feeling weak and 
confused. An illness of six weeks ensued, with headache, 
delirium, much worse at night, and high fever. On recov- 
ering it was thought unwise to keep him on duty, and he 
was most imprudently sent back on horseback to San An- 
tonio, — a four days' ride. A relapse occurred, and he was 
again ill, with like symptoms, during two weeks, when he 
gradually recovered, the headache becoming by degrees 
more rare, until in the summer of 1870, after exposure to 
sun-heat, the cephalalgia became again more frequent and 
more severe. The winter which followed alone gave full 
relief. In April, 1871, in New Mexico, the great heat re- 
newed his pain, and before July he fell twice, owing to sud- 
den weakness with vertigo. During this summer he had 
frequent headaches, with many dizzy spells, which at length 
were accompanied with loss of consciousness without spasm. 
At this time also he suffered from sense of choking, and 
there was also steady pain high up in the right side of the 
neck, with buzzing in the right ear, tenderness of the mas- 
toid process, and stiffness of the muscles below and back of 
this region. The attacks lessened with cooler weather, and 
in November and December there were none. I should 



124 THERMIC FEVER, OR SUNSTROKE. 

add that from July he had had, when excited, tremor of the 
right arm, but, notwithstanding these grave symptoms, had 
remained on duty. January i, 1872, when much annoyed 
and angry, a sudden spell of giddiness came on, with numb- 
ness of the right arm, and twitching of the right hand. From 
thence forward he dragged the leg a little in walking. He 
came to Philadelfhia in March, 1872, and in the interval 
had several attacks, which were alike, and began with a 
sudden increase of the post-aural pain, which he properly 
says is a sense of numbness with pain. The pain seems to 
him to ascend above and behind the ear, and to run for- 
ward on to the forehead. Meanwhile, the head feels full, 
vertigo comes on, objects seem to rotate from left to right, 
and loss of consciousness, without spasm, follows, after 
which he sleeps, or is dull and drowsy. Until he came to 
this city the leg and arm were increasingly feeble, the tremor 
easily excited, and the headaches frequent. The palsy was 
not, however, always the same, and in a time of excitement 
and danger, during his homeward journey, he suddenly 
seized the reins of a pair of unruly horses, and then discov- 
ered that for some days after he could walk with ease. Per- 
haps, feeling his weakness, he had not before this ventured 
so much, and this seeming return of power was only a dis- 
covery of a capacity always existing. 

Mr. had no new attack until June i, 1872, at which 

date he was free of headaches, and was rapidly gaining 
strength. The first attack in June was preceded by pain 
down the right neck, shoulder, and arm. A second fit fol- 
lowed, June 9, and it then appeared that all his symptoms 
had darkened. 

When seen by me in consultation, June 12, 1872, this was 
his condition : The mind said to be unimpaired ; memory 
unaltered, or, if at all changed, it is so in regard to names ; 
temper as usual ; questioned closely, he thinks that an hour 
before an attack his memory of dates and names becomes 



SEQUELS, 125 

much obscured ; hearing unaffected, but at times has had 
buzzing in the right ear ; taste and smell as usual. I detected 
no lesion of either eye bearing on the case. After the attacks 
he has seen double for an hour, but now there is no squint, no 
difficulties as to the accommodation. The field of vision is 
entire, the acuteness of vision normal, and the pupils, alike 
in size, play readily under changes of light. Dr. Wm. 

Thomson was kind enough to see Mr. with me, and he 

also found no changes in the disks of either eye, and no 
evidence in them of past or present mischief. The sensi- 
bility of the neck and face was examined with care, and 
with these curious results : The entire distribution of the 
fifth nerve was dyssesthetic, while also over the eye and in 
front of the ear the sense of touch was lost altogether. The 
ear and cheek and lips were least affected, but there was 
still more complete loss of touch over the whole back of the 
neck and head to the middle line. A needle-prick was felt 
anywhere in the face, but not at all below the ear, or at any 
point of the neck from the third cervical vertebra to the 
occipital bos. 

The mastoid process feels at times painful, and is slightly 
tender on pressure. Deep pressure on the muscles below 
and behind the right ear causes some pain, and he is never 
free from some sensation in this region, which ranges from 
annoyance to intense pain. The state of tactile sensation 
in the right hand varies, and has varied so as that at times 
he has slight loss of feeling, at others much more. When 
first examined by me, the localizing power and the sense of 
pain and temperature were all lessened. The compass- 
points could not be separated widely enough to be felt as 
two on the fingers of the right hand. The feeling of the 
right leg was rather less disturbed. 

There were no motor-palsies of any of the cerebral nerves. 
The muscles of the right side of the neck were said to be 
at times stiff, and were always sore. Speech normal. The 



126 THERMIC FEVER, OR SUNSTROKE. 

right hand had, by the dynamometer, one-quarter the power 
of the left. The right hand was in a state of tremor, in- 
creased by the examination. During perfect rest it did 
shake. When he made voluntary motions with the hand 
it ceased to shake. The limb had every movement, but 
each was feeble. He could walk with only a slight shuffle 
in the gait. 

Heart, lungs, abdominal organs, healthy ; appetite good ; 
digestion natural ; bov/els regular ; urine, two specimens, 
specific gravity 1024, no deposit, no albumen or sugar. 

The treatment consisted of iodide and bromide of potas- 
sium, with corrosive sublimate. The post-aural region was 
leeched four times. When the first leeches were applied he 
did not feel them, but before they fell off he felt them. The 
second leeching was felt at once, and the effects were mani- 
fest in the almost entire return of feeling in the fifth nerve 
and its partial restoration in the cervico-occipital region. 
The pain also disappeared, and the head felt lighter and 
better. From thence the gain in other respects has been 
steady and remarkable. 

June 29, 1872. — The leeching was repeated yesterday, and 
three ounces taken. A previous dry-cupping afforded less 
relief; that from the leeching is notable, and what is thus 
gained is also kept. He thinks the sensation of the hand 
better, but it is still so dull that the width of the fingers is not 
space enough to enable me to separate the compass-points 
so that they shall seem to be two. On the neck and face 
the sense of touch is still improving, and everywhere alight 
contact is felt, save at the centre of the cheek, over a space 
a half- inch in diameter; even here a deep pressure or 

rough touch is felt. Mr. ordered to the seaside, and to 

continue treatment. 

This case is one of general interest. There was no sus- 
picion of specific disease. It was clearly due to sunstroke. 
In all probability there was some inflammatory state of the 



SEQUELS. 127 

membranes surrounding the upper end of the cervical cord, 
and a Hke state of the basal cerebral membranes. Both cen- 
tres of disturbance must have been on the right side. The di- 
agnosis, although not altogether satisfactory, seems to accord 
pretty well with the results of treatment, which have been 
decided and satisfactory. Many of his symptoms might 
lead one to suspect the presence of a tumor, but I do not 
see how a mass could be so situated as to occasion all the 
troubles, while the careful and repeated studies of the eye 
leave no doubt as to the absence of the usual ocular signs 
of basal tumor. 

I think the evidence now brought forward is 
sufficient to establish the frequency of meningitis 
following sunstroke, and that the fixed, intense 
headache so often complained of is probably due 
to such cause. 

Whether the epilepsy and insanity which occa- 
sionally follow sunstroke are really due to chronic 
meningitis or not, I cannot say. 

Maclean states that the epileptic fits usually 
subside when the patient is removed to a cool 
climate. 

There is often, however, after coup de soldi ^ a 
condition of simply deranged innervation, with 
headache, dyspepsia, etc., in which there is no suf- 
ficient reason to believe that actual inflammation 
of the meninges exists. Such cases are readily dis- 
tinguished by the headache being irregular and 
shifting, sometimes absent, sometimes present, 
sometimes frontal, sometimes occipital, etc. 



128 THERMIC FEVER, OR SUNSTROKE. 

Treatment, — If the view here taken be correct, 
the indications for treatment are very plain. First 
and most important among them is the avoidance 
of exposure to heat, it being evident that every 
renewal of the original irritation will add fresh fuel 
to the fire. This being borne in mind, the treat- 
ment resolves itself into that of chronic meningitis, 
which it is not necessary here to discuss. It is, 
however, interesting to note that at Netley, Eng- 
land, without apparently any definite idea as to the 
true pathology, they have, as the result of clinical 
observation, settled upon a good plan of treatment; 
for Maclean (Joe. eit.) says, " When the pain is fixed 
and severe, long-continued counter-irritation to the 
nape and a course of iodide of potassium some- 
times permanently relieve.'' 

In the milder forms of the after-affection, the 
physician's duties may often be limited to simple 
hygienic measures and treatment of symptoms. 

In these cases, as well as in the more serious, 
Dr. Maclean lays stress upon the necessity of at- 
tending to the functions of the skin, which he states 
always to be profoundly perverted. 

THE ENP. 



IMPORTANT MEDICAL WORKS 

RECENTLY PUBLISHED BY 

J. B. LIPPINCOTT & CO., 

716 and 717 MARKET STREET, Philadelphia. 



A New and Revised Edition of the United States 

Dispensatory. The DISPENSATORY OF THE UNITED 
STATES OF AMERICA. By George B. Wood, M.D., and 
Franklin Bache, M D. Thirteenth Edition. Carefully Revised 
and Corrected, with Numerous Important Additions, One Vol- 
ume, Royal 8vo. Superfine paper. Sheep. ^lo.oo. 

Hand-Book of Operative Surgery. By John H. 

Packard, M.D., Sec. of the Coll. of Physicians of Phila., etc. 
With Fifty-four Steel Plates, and Numerous Illustrations on Wood. 
8vo. Extra cloth. ^5.00. 



"Its distinguishing feature is abundant 
illustration, and in this respect it is un- 
equaied by any hand-book with which 
we are acquainted. . . . To students 
and practitioners who have not the fre- 



quent opportunity of witnessing practical 
surgery, the volume before us will prove 
of unquestionable value." — N. Y. Med. 
Record. 



Medical Diagnosis with Special Reference to Prac- 

tical Medicine. A Guide to the Knowledge and Discrimination 
of Diseases. By J. M. Da Costa, M.D. Illustrated with En- 
gravings on Wood. Third Edition, Revised and Enlarged, Svo. 
Fine cloth, ;^6.oo; sheep, $7 00. 

*' To digest and memorize the matter I book which will do credit to our national 
of all its pages will well repay the labor medical literature." — Amer. your, of 
it costs. It may be welcomed as a text- j Med. Sciences. 

A Compend of Materia Medica and Therapeutics. 

For the Use of Students. By John C. Riley, A.M., M.D., Prof, 
of Mat. Med. and Therap. in the Nat. Med. Coll., etc. Svo. 
Extra cloth. $3.00. 

are very concise and remarkably accu« 
rate." — N. Y. Med. Journal. 



'* Prof. Riley has done his work very 
•ell. . . . The descriptions of the 
ATious articles of the Materia Medica 



12 



PUBLICATIONS OF J. B, LIPPINCOTT 6- CO, 



A Handbook of Medical Microscopy, By Joseph 

G. Richardson, M.D., Microscopist to the Pennsylvania Hospital, 
Philadelphia. i2mo. Fine cloth. ^2.25. 



This work is designed to supplement by- 
minuteness of detail and accuracy of illus- 
tration the practical instruction so gensr- 
ally necessary for an advantageous use of 
the instrument as an aid to the diagnosis 
of disease. It should bc2 in the hands of 
every medical man who either possesses 
a microscope or contemplates purchasing 
one, since, in the latter case, it will often 
save many times its own cost by advice 



in regard to the selection of apparatus ; 
while the ad\-anced student and practi- 
tioner of medicine will find in it brief but 
precise directions for the various kinds of 
research, according to the most recent 
discoveries, as well as for the avoidance 
of those errors of interpretation which are 
sometimes so mortifying to th?; inexpe- 
rienced observer. 



Rajtd's Medical Chemistry. A New Edition of 

Elements of Medical Chemistry. Ly B. Howard Rand, M D., 
Professor of Chemistiy in the Jefferson Medical College. Care- 
fully Revised, with Additions. Illustrated. i2mo. Extra cloth, 
^2.00; sheep, ^2.50. 



" We commend it to the student as the 
best zfade-inecuJH we have yet seen. We 
shall also adopt it as a text-book in our 

" Prof. Rand has long held, as he has 
deserved, a high position as a teacher of 
Chemistry. The simplicity, clearness, 
tnd absence of all superfluity, which 
tharacterize his lecture-room demonstra- 
tions, are seen in this book from the be- 
ginning to the end. We would especially 
•remark the due apportionment of space 



College of Pharmacy." — St, Louis Med 
Reporter. 



to its different subjects. . . . Medi- 
cal students may feel themselves greatly 
indebted to Prof. Rand for furnishing 
them with a text-book so portable, con- 
venient, and concise, and yet so lucid and 
full, as to the really essential elements of 
chemistry." — Medical and Surgical Re- 
Porter, Philadelphia. 



Opium and the Opium-Appetite. With Notices of 

Alcoholic Beverages, Cannabis Indica, Tobacco, Coca, Tea, and 
Coffee, in their Hygeienic Aspects and Pathologic Relations. By 
Alonzo Calkins, M.D. i2mo. Extra cloth. ^1.75. 



This volume forms an elaborate treatise 
jespecting the character and use of stim- 
jiants. Its subject is one that is daily 



assuming greater importance, and in 
which all classes of thoughtful readers 
are more or less interested. 



Microscopical Manipulation.^ being the Subject- 

matter of a Course of Lectures delivered before the Quekett Micro- 
scopical Club, JantLary — Aprils 1869. By W. T. Suffolk, 
F.R.M.S. Illustrated with Forty-nine Engravings and Seven 
Lithographs. Crown 8vo. Fine cloth. ^2.00. 



■ Mr. Suffolk gives an explanation of 

-Tie construction of the microscope, and 

«ar, practical directions for preparing 

liides ana oincr apparatus, mounting and 



preserving objects, and conducting a great 
variety of experiments and researches. 
The book is weil illustrated. "—iV^. York 
Tribune. 



PUBLICATIONS OF J, B, LIPPINCOTT ^ CO. 



A System of Medicine. Edited by J. Russell Rey^ 

nolds, M.D., F.R.C.P., and contributed to by the most eminent 
Physicians of England. Vol. I., General Diseases; or, Affections 
of the Whole System, i. Thos<=; Determined by Agents operating 
from Without. II. Those Determined by Conditions existing 
Within the Human Body. A New Edition^ thoroughly Revised 
and Enlarged. Extra cloth, ;^6.oo; sheep, ^7.25. 

In a review of the First Edition, the I thority on the subjects which they re- 
London Lancet s^\A\ " It is unnecessary I spectively handle; and we congratul.ite 
to say a word in favor of the high claims I the editor on his distinguished success in 
of all these gentlemen to speak, with an- j securing the services of such a staflf." 

Manual of Hypodermic Medication, By Roberts 

Bartholow, a.m., M.D., Professor of Materia Medica and Thera- 
peutics in the Medical College of Ohio; author of the Russell and 
Jevvett Prize Essay, of the National Medical Association Prizt 
Essay on Atropia, for 1869, etc. etc. i2mo. Toned paper. 
Extra cloth. ^^1.50. 

"Dr. Bartholow has written a new chapter in the history of Therapeutics."— 
Phila. Press. 

Sleep and its 'Derangements. By W, A. Hammond^ 

M.D., Professor of Diseases of the Mind and Nervous System, and 
of Clinical Medicine in the Bellevue Hospital Medical College, 
New York, etc. i2mo. Toned paper. Extra cloth. ^1.75. 



press our gratification that the work has 
underg >ne such careful revision." — Cin- 
cinnati Lancet and Observer. 



"When the original monograph ap- 
peared, it received our careful attention 
and commendation ; and now we have 
only to repeat our good words, and ex- 

A Treatise on the Diseases and Surgery of the 

Mouth, Jaws, and Associate Parts. By James E. Garretson, 
M.D., D.D.S., etc. Illustrated with Steel Plates and numerous 
Wood-cuts. 8vo. Extra cloth. $7.50. 

"There is no work of the kind which bears comparison with it." — Pacific Med. 
and Surg, jfournal. 

Percussion and Auscultation as Diagnostic Aids, A 

Manual for Students and Praciitioners of Medicine. By Dr. Carl 
HopPE, Assistant Physician to the Sixth Westphalian Regiment of 
Infantry. Translated by L. C. Lane, M.D. l6mo. Tinted 
paper. Extra cloth. ^1.50. 

A masterpiece in both thoroughness and brevity. 



The Medical Times. 

A SEMI-MONTHLY JOURNAL OF 

Medical and Surgical Science. 



The leading features of this Periodical, which is intended to supply 
an important want, and to subsei^ve the growing intelligence of the 
Medical Profession, are as follows : 

I. There is a department in each issue for Original Lectures, which 
are furnished by the most distinguished clinical teachers in this and 
other cities. 

II. The space devoted to Original Communications in each number 
is large, and articles wiil be coxitributed to it by many of the most 
eminent American authors. 

III. There is a department devoted to the publication of the records 
of Important Cases, and of brief summaries illustrating Hospital 
Practice. 

IV. The Journal is open to the free and thorough discussion of all 
important questions relating to Medical Science, Hygiene, Medical 
Jurisprudence, Medical Education, Hospital Management, and kindred 
subjects. 

■ V. Abstracts of the Transactions of Medical and Scientific Societies 
are furnished. 

VI. In arranging the department of Foreign and Domestic Corre- 
spondence, care has been tai^en to secure frequent and full accounts 
of the progress of medicine, and of all important medical movements 
in the principal cities of the world. 

VII. Short but careful Reviews of the more important medical pub- 
lications form a feature. 

VIII. Reports of recent Improvements, Discoveries, and Important 
Obsers^ations in all branches of Medical Science are furnished in each 
issue. 

IX. Under the head of Medical Miscellany, an ample summary is 
presented of matters of general interest to the profession. 

The Publishers are happy to be able to announce that among the 
regular contributors to this Journal are many of the most distinguished 
writers in the Medical Profession. 

The Medical Times is published on the ist and 15th of each month, 
and contains Twenty Imperial 8vo pages. Illustrations being inserted 
when necessaiy for the elucidation of the subjects discussed. 

Yearly Subscription, ^4.00, in advance. Single Number, 20 

CENTS. 

J. B. LIPPINCOTT Sc CO., Publishers, 

715 and yiy Market Street^ PJiiladelphia, 



LIST OF PUBLICATIONS 



OF 



J B. LIPPINCOTT & Co. 

PHILADELPHIA. 



Will be sent by inail^ post paid, on receipt of the price* 



The Albert N'^Tanza, Great Basin of the Nile^ 

and Explorations of the Nile Sources. By Sir Samuel Whitb 
Baker, M. A., F. R. G. S., &c. With Maps and numerous Illus- 
trations, from sketches by Mr. Baker. New edition. Crown 8vo. 
Extra cloth, ;^3. 



" It is one of the most interesting and 
instructive books of travel ever issued ; 
and this edition, at a reduced price, will 
bring it within the reach of many who 
have not before seen it." — Bosiofijfournal. 



" One of the most fascinating, and cer- 
tainly not the least important, books of 
travel published during the century." 
Boston Eve. Tratiscript. 



The Nile Tributaries of Abyssinia^ and the Szvord- 
Hunters of the Hamran Arabs. By Sir Samuel White Baker, 
M. A., F. R. G. S., &c. With Maps and numerous Illustrations, 
from original sketches by the Author. New edition. Crown 
8vo. Extra cloth, $2.75. 



** We have rarely met with a descriptive 
work so well conceived and so attractively 
written as Baker's Abyssinia, and we cor- 



dially recommend it to public patronage 
... It is beautifully illustrated." — ^^V. O 
Times. 



Eight Years'^ Wandering in Ceylon. By Sir 
Samuel White Baker, M. A., F. R. G. S., &c. With Illustra- 
tions. i6mo. Extra cloth, $1.50. 



•*Mr. Baker's description of life in Cey- 
lOn, of sport, of the cultivation of the soil, 
of its birds and beasts and insects and rep- 
tiles, of its wild forests and dense jungles, 
of its palm trees and its betel nuts and in- 
toxicating drugs, will be found very in- 
teresting. The book is well written and 
l>eautifuily printed." — Bait. Gaaette. 



" Notwithstanding the volume abotinds 
with sporting accounts, the naturai history 
of Ceylon is well and carefully described, 
and the curiosities of the famed island are 
not neglected. It is a valuable addition to 
the works on the East Indies." — Pkiia,. 
Lutheran Observer. 



PUBLICATIONS OF J. B. LIPPINCOTT ^ CO. 

The American Beaver and his Works. By Lewis 

H. Morgan, author of "The League of the Iroquois." Hand- 
somely illustrated with twenty-three full-page Lithographs and 
numerous Wood-Cuts. One vol. 8vo. Tinted paper. Cloth 
extra, $5. 



** The book may be pronounced an ex- 
pansive and standard work on the Ameri- 
can beaver, and a valuable contribution to 
science. "—^V. V. Herald. 

" The book is an octavo of three hun- 
dred and thirt}' pages, on very thick paper, 
handsomely bound and abundantly illus- 
trated with maps and diagrams. It is a com- 
plete scientific, practical, historical and des- 



criptive treatise on the subject of which it 
treats, and will form a standard for those 
who are seeking knowledge in this de- 
partment of animal life. ... By the pub- 
lication of this book, Messrs. J. B. Lii>- 
pincott & Co., of Philadelphia, have really 
done a service to science which we trust 
will be well rewarded "—Boston Even, 
Traveler. 



The Autobiography of Dr. Benjamin Franklin. 

The first and only complete edition of Franklin's Memoirs. Printed 
from the original MS. With Notes and an Introduction. Edited 
by the Hon. John Bigelow, late Minister of the United States to 
France. With Portrait from a line Engraving on Steel. Large 
i2mo. Toned paper. Fine cloth, beveled boards, $2.50. 



"The discovery of the original auto- 
craph of Benjamin Franklin's character- 
istic narrative of his own life was one of 
the fortunate events of Mr. Bigelow's dip- 
lomatic career. It has given him the op- 
portunity of producing a volume of rare 
bibliographical interest, and performing a 
valuable service to the cause of letters. 
He has engaged in his task with the en- 
thusiasm of an American scholar, and 



completed it in a manner highly credit- 
able to his judgment and industry." — The 
Neiv Vork Tribune. 

" Every one who has at heart the honor 
of the nation, the interests of Am -rican 
literature and the fame of Frankh i will 
thank the author for so requisite a national 
service, and applaud the manner and 
method of its fulfillment." — Boston Even, 
Transcript 



The Dervishes. History of the Dervishes; or^ 

Oriental Spiritualism. By John P. Brown, Interpreter of the 
American Legation at Constantinople. With twenty-four lUus- 
tradons. One vol. crown 8vo. Tinted paper. Cloth, $3.50. 



" In this volume are the fruits of long 
years of study and investigation, with a 
great deal of personal observation. It 
tre?ts, in an exhaustive manner, of the 
belief and principles of the Dervishes. 



. . . On the whole, this is a thcroughlj 
original work, which cannot fail to be- 
come a book of reference.'' — TJie Pkilada, 
Press. 



N'ew America. By Wm. Hef worth Dixon. Fourth 

edition. Crown 8vo. With Illustrations. Tinted paper. Extra 
cloth, $2.75. 



- fn this graphic volume Mr. Dixon 
sketches America!/ en and women sharp- 



ly, vigorously and truthfully, under every 
aspect." — Dublin University Magazine. 



PUBLICATIONS OF J. B. LIPPINCOTT 6* CO. 



Biilzvcr's Novels. Globe Edition. Co7nplete in 

twenty-two volumes. With Frontispiece to each volume. Beau- 
ti fully printed on fine tinted paper. i6mo. Extra cloth, $33 
extra cloth, gilt top, $38.50; half calf, neat, $55 ; half Turkey, gir 
top, $66; half calf, giit extra, $66. Each novel sold separately, 
as below, m extra cloth, at $1.50 per volume. 



The Caxtons i vol. 

My Novel 2 vols. 

What will He Do with It ?..2 vols. 

Devereux^ i vol. 

Last Days of Pompeii. . ..I vol. 
Leila, Calderon and Pilgrims, i v. 

Rienzi I vol. 

The Last of the Barons. . i vol. 

Harold i vol. 

Eugene Aram I vol. 

"The Globe edition of Bulwer is very 
oeat and satisfactory — more .saiisfactoiy 
tlian any other issued in this country." — 
Fhilada. North A mericati. 

"The Globe edition 's lemarkable for a 
judicious combination ct c;ieapness, legi- 
bility and beauty." — C/iarleston Courier. 

"We have repeatedly borne witness to 
"he pre-eminence of the Globe over all 
other editions, in respect to cheapness, 
neatness and convenience of size." — Cin- 
cinnati Gazette. 

" The ciear-cut tx-pe, delicately-tinted 
paper and tasty binding of this Globe edi- 
tion of Bulwer's works cannot be awarded 
too much praise."' — Rjiral Neiv Worker. 

" We repeat what we have so often be- 
fore stated — that the Globe edition is the 
best ever issued on this side of the Atlan- 
tic." — New Orleans Times. 



Zanoni i voL 

Pelham i voL 

The Disowned I vol. 

Paul Clifford I vol 

Ernest Maltravers I vol 

Godolphin i voL 

Alice I vbL 

Night and ISIorning i vol. 

Lucretia. i voL 

A Strange Story i vol 

*' The Globe edition of Bulwer fijmishet 
a model well worthy of imitation." — 
Philada. A ^e. 

"As to execution and price, there is no 
better edition in the market." — Chicag6 
EveJiing Jozirnal. 

" We congratulate this well-known Phi- 
ladelphia publishing house upon furnish- 
ing so complete, so legible, so compact 
and so beautiiul an edition of the writing.4 
of this great novelist. The Americai 
book-buying and book-reading public wii^ 
not fail to place this fine edition upon their 
library shelves. It is the best cheap edition 
of Bulwer that we have ev^r seen. It is 
offered at the low price of $1.50 per volume 
at which price tlie purchaser gets the besi 
part of the bargain." — Providence Even- 
ing Press. 



Readers Novels. Ilhisti'ated Standard Edition of 

Charles Reade's Novels. Complete in ten vols. i2mo. With 
Engraved Frontispiece and Vignette Title to each. Handsome!) 
bound in extra cloth. Price, $15 per set Extra cloth, gilt top 
$17 per set. Sold separately, in extra cloth, as follows : 



Hard Cash $1-75 

Love me Little Love me 
Long 1.50 



The Cloister and the Hearth$i.75 

Gritfith Gaunt 1. 50 

Peg Woffington 1.25 



Never too Late to Mend. . 1.75 1 Christie Johnstone 1.25 

White Lies i-5o , The Course of True Lcn^e 

Foul Play 1.50 \ Never did Run Smooth, t 2< 



PUBLICATIONS OF J, B, LIPPING OTT dr* CO. 



Our Own Birds of the United States, A Familiar 

Natural History of the Birds of the United States. By William 
L Baily. Revised and Edited by Edward D. Cope, Member of 
the Academy of Na ^:ra( Sciences. With numerous Illustrations. 
i6mo. Toned papei. Extra cloth, i^i.50. 



rangement and system that will often makg 
it a heipful work of reference for oldei 
naturalists." — Fhilada. Eve7i. Bulletin. 

"To the youthful, ' Our Own Birds' ii 
likely to prove a bountiful source of pleas- 
ure, and cannot fail to make them thor- 
oughly acquainted with the birds of the 
United States. As a science there is none 
more agreeable to study than ornithology. 
We therefore feel no hesitation in com- 
mending this book to the public. It is 
neatly printed and bound, and is profusely 
illustrated." — New York Herald. 



" The text is all the more acceptable to 
the <,enerai reader because the birds are 
called by the'r popu'ar names, and not by 
the scientific titles of the cyclopicdias, and 
we know them at once as old friends and 
companions. We commend this unpre- 
tending little book to the public as pos- 
sessing an interest wider in its range but 
similar in kind to that which belongs to 
Gilbert Whites Natural History of Sel- 
borne. ' — N. V. Et>efi. Post. 

"The whole bock is attractive, supply- 
ing much pleasantly-conveyed information 
for young readers, and embodying an ar- 

A Fezu Friends^ and How They Amused Them- 

selves. A Tale in Nine Chapters, containing descriptions of Twenty 
Pastimes and Games, ai\d a Fancy- Dress Party. By M. E. Dodge, 
author of "Hans Brinker," &c i2mo. Toned paper. Extra 

cloth, $1.25. 

"This convenient httle encyclopaedia 
strikes the proper moment most fitly. The 
evenings have lengthened, and until they 
again become short parties will be gath- 
ered everywhere and social intercourse 
will be general. But though it is compar- 
atively easy to assemble those who would 
be amused, the amusement is sometimes 
replaced by its opposite, and more resem- 
bles a religious meeting than the juicy en- 
tertainment intended. The ' Few Friends' 
djescribes some twenty pastimes, all more 



or less intellectual, all provident of mirth, 
requiring no preparation, and capable ol 
enlisting the largest or passing off with the 
smallest numbers. The description is con- 
veyed by examples that are themselves 
'as good' as a play,' The book deserves 
a wide circulation, as it is the missionary 
of much social pleasure, and demands no 
more costly apparatus than ready wit and 
genial disposition." — Fhilada. North 
A mericaiu 



Cameos from English History. By the author of 

**The Heir of Redclyffe," &:c W^ith marginal Index. I2ma 
Tinted paper. Cloth, jii.25 ; extra cloth, $1.75. 



" An excellent design happily executed* 
-N.Y. Times. 



" History is presented in a very attractive 
jmd interesting form for young folks in this 
work." — Pittsburg Gazette. I 

The Diamond Fditioft of the Poetical Works of 

Robert Burns. Edited by Rev. R, A. W'illmott. New edition, 
With numerous additions. i8mo. Tinted paper. Fine cloth, $1, 



' This small, square, compact volume is 
jjnnted in clear type, and contains, in three 
hundred pages, the whole of Burns' poems, 
nith a glossary and index. It is cheap, 



elegant and convenient, bringing the works 
of one of the most popu.ar of British poets 
within the means of every reader." — Bos- 
ton Even. Transcript. 



PUBLICATIONS OF J. B, LIPPINCOTT ^ CO. 



Thackeray s Works. The Standard Library Edi* 

tion of the Works of W. M. Thackeray, Elegantly Illustrated 
with many Hundred Steel Plates and Wood-Cuts. Complete in 
twenty-two volumes. Large crown 8vo, printed in large type, on 
superfine toned paper, and handsomely bound in extra cloth, gilt, 
beveled boards. Price, $3.50 per volume ; extra cloth, gilt top, 
^3-75 P^r volume; half Turkey morocco, ^5.50 per volume ; lali 
calf, gilt, $5.50 per volume ; treed calf, gilt edges, $7.50 per volume. 
Each novel sold separately, as follows : 



Vanity Fair 2 vols. 

Pendennis 2 vols. 

Philip 2 vols. 

The Newcomes 2 vols. 

The Virginians 2 vols. 

Henry Esmond. 

The Paris Sketch-Book, &c. 

Memoirs of Barry Lyndon, Esq., 

&c. 
Christmas Books. 
Burlesques. 

This edition of Mr. Thackeray's works 
contains the autlior's latest corrections, 
printed in the best style from new type, 
with all the original, and some new, illus- 
trations, by Du Maurier, Doyle and War- 
ner ; the wood engravings being printed 
from the original wood blocks, instead of, 
as hitherto, from stereotype casts. 

The series consists of twenty-two vol- 



The Irish Sketch-Book, &c. 

The Book of Snobs, &c. 

Roundabout Papers. 

Ballads and Tales. 

The Four Georges and English 
Humorists. 

Dennis Duval, Lovel the Wid- 
ower, &c. 

The Story of Catherine, Fitz- 
boodle Papers, &c. 



times, and contains all of Mr. Thackeray's 
writings, which it is believed he would 
have desired should be included in a stan- 
dard edition of his works. 

Much new and interesting matter has 
been printed in this series, and every care 
has been taken to make it a complete as 
well as a permanent edition. 



Incidents of the United States Christian Commis- 
sion. By Rev. Edward P. Smith. With Steel Plates and 
numerous Wood-Cut Illustrations. 8vo. Extra cloth, ^3. Sub' 
scription Book. 



*'A deeply interesting narrative of events 
in the various National armies during the 
late war. . . . Many of these Incidents 
were exceedingly affectinu:, and will be 
found very profitable as well as attractive 
reading. ' ' — Cincumati Gazette. 

'• This is a book of thrilling interest. 
The incidents connected with the five 
whoi sand Delegates of the Christian Com- 
misi-ion, on battle fields, in fever wards, 
And beside the dying, can never lose in- 
terest among Christian and patriotic Amer- 
icans. The volume is a very attractive 
one, and should have a large circulation." 
— Presbyterian Bantier. 



" We defy any one to take up this won- 
derful book and read it through without 
being affected to tears or moved at times 
to laughter . . . The volume is suited to 
minister or layman, and we trust it will 
have a large circulation." — Chrojiicle and 
A dvertiser. 

" It is a book for the family, for the Sab- 
bath-School Library, and for the pastor'f 
study. Ministers and otiiers will find it 
full of apt and striking illustrations, to ba 
used in communicating gospel truth. It 
cannot but have a wide and steady sale." 
— A mericati Guardian. 



PUBLICATION^^ OF J. B. LIPPINCOTT & CO. 



True Love. By Lady di Beauclerk^ azttkor of 

"A Summer and Winter in Norway," etc. i2mo. Fine cloth. 



*' Many of the scenes of her novel are 
drawn with truth and vigor. . . . The in- 
terest is sustained ihroughout the story.** 
— Hearth and Home. 



$1.25. 

" Is a pleasing little story well told." — 
A^. }'. Independent. 

*' This pleasantly told love story presents 
"hCtures of English society that will repay 
li; reader. ' — Pittsburg Gazette. 

Carhno. By the author of ^^ Doctor Antonio^ 

*' Lorenzo Benoni," etc. 8vo. Illustrated. Paper cover. 35 cents. 

pie and wholesome story charmingly told." 
— Brooklyn Eagle. 

*' Strange and deeply interesting." — N 
V. Hearth and Ho>ne. 



" It is beautifully written, and is one of 
the best delineations of character that has 
been written lately." — Phila. Day. 

" It is a capital little story. ... A sim- 



Walter Ogllby. A Novel. By Mrs. J. H. Kin- 

zie, author of " Wau-bun, etc." Two volumes in one vol. i2mo. 
619 pages. Toned paper. Extra cloth. $2. 



*' One of the best American novels we 
have had the pleasure of reading for some 
time. The descriptions of scenery are 
spirited sketches, bringing places before 
the reader, and there is nothing strained, 
sensational or improbable in the cleverly- 



constructed incidents. Even the graduat 
ing week at West Point, though a liack 
neyed subject, is pre.sented with tlie charn? 
of freshness as well as reality. This is 
a thoroughly good novel." — Philada. 
Press. 



Askaros Kassis^ the Coj)t. A Romance of Modern 

Egypt. By Edwin de Leon, late U. S. Consui-General for Egypt 
i2mo. Toned paper. Extra cloth. $1.75. 



*' This book, while possessing all the 
characteristics of a Romance, is yet a 
vivid reproduction of Eastern life and man- 
ners."' — N. Y. Times. 

'* He has written us this thrilling tale, 



based on miscellaneous facts, which he 
calls 'A Romance of Modi-^'m Egypt,' and 
in which he vividlv depicts the life of 
rulers and people." — Chicago Advance 



Beyond the Breakers. A Story of the Present 
Day. By the Hon. Robert Dale Owen. 8vo. Illustrated. 
Fine cloth. $2. 



All readers of taste, culture and 
diought will feel attracted and impressed 
Dy it. . . . We have, for ourselves, read it 
with deep interest and with genuine plea- 



sure, and can say for it that which we 
could say of few novels of to-day— thai 
we hope some time to read it over again.** 
—N. Y. IndepeTuUnt. 



Compensation; or ^ Always a Future, A IVoveL By 

Anne M. H. Brewster. Second edition. i2mo. Fine cloth. $1.75. 



** It is an interesting work, and particu- 
(arlv so to tliose who are musically in- 
clined, as much useful infortnation maybe 
gained from it." — Bosiofi Post. 

" We recommend this book to all who 
ire not longing tor agony ; for such patrons 



it is too gentle and too delicate." — Phila. 
No rth A 771 erica n . 

"The writer exhibits a happy talent tbj 
description, and evinces a tare taste and 
genius for music." — Boston Kec0rd4*r 



PUBLICATIONS OF J. B, LIPPINCOTT 6- CO. 

Advice to a Wife on the Manageinent of ker own 

Health, and on the Treatment of some of the Complaints incidental 
to Pregnancy, Labor and Suckling ; with an Introductory Chapter 
especially addressed to a Young Wife. By Pye Henry Chavasse, 

M.D. Eighth edition, revised. i6mo. Neatly bound in cloth. $1.50. 



■*From this advice any woman may 
gather some precious ideas as to the care 
sf her health. The manual is very popu- 
lar in England, where it has passed through 
iigrt rapid editions, and we know of no 
limiiar work where an equal amount of 



doctor's lore is given in the style of plain 
modern convarsation." — Fhilada. Even. 
Buiietin. 

" Possesses undoubted value for those 
to whom it is addressed." — Chicago Jour- 
nal. 



and has undergone a careful revision by 
Sir Charles Locock, the first physician- 
accoucheur to Queen Victoria." — N.V 
Evefi. Post. 



Advice to a Mother 07i the Management of her 

Children, and on the Treatment on the moment of some of their 
more pressing Illnesses and Accidents. By Pye Henry Chavasse, 
M.D. Ninth edition, revised. i6mo. Neatly bound in cloth. $1.50. 

" For such, and for those who want to 
rear children judiciously, but need proper 
counsel, the present volume is one of the 
most valuable treatises ever published. 
The new edition contains many new notes, 

Maternal Manageme7it of Infancy, For the tcse 

of Parents. By F. H. Getchell, M.D. i6mo. Cloth. 75 cents. 

"We warmly recommend it for its good | " This little work is deserving the care- 
sense, clearness and brevity.'" — The Phila. I ful attention of all entrusted with th« 
Press. I management of infants." — TJie hiq^iiro. 

Dictionary of Daily Wants, A Cyclopcedia em* 

bracing nearly 1200 pages of Sound Information upon all matters 
of Practical and Domestic Utility, containing 980 Engravings. One 
handsome i2mo vol. Half Roxburgh, $3.75. 



channels, into one arrangement and sys- 
tem, by which they may be easily foun- 
and applied. 

The sale of nearly 100,000 copies of this 
work affords the best evidence of its in 
trinslc value. 



The " Dictionary of Daily Wants" may 
be said to have done for matters of Prac- 
tical Utility in Domestic Affairs what the 
great naturalist Linnaeus did for the Sci- 
ence of Botany. It has brought thou- 
sands of useful items, scattered in dis- 
order through an unlimited number of 

Dictionary of Useful KnovAcdge. A Book of 

Reference upon History, Geography, Science, Statistics, etc., with 
570 Engravings. A Companion Work to the "Dictionary of Daily 
Wants." Two handsome i2mo vols., containing aver 1500 pageSi 
Half Roxburgh, $5. 

Dictionary of Medical and Surgical Knowledge ^ 

and Complete Practical Guide in Health and Diseases, for Families. 

With 140 Engravings. One handsome i2mo vol. of 755 pages. 

Half Roxburgh, $2.50. 

The Editor of this volume has brought I professiona. study, to the task of prepar 
Jie experience of more than thi-rty years j ing this work. 
e? active txactice, and ov^r/^-yty years of 1 



PUBLICATIONS OF J. B. LIPPINCOTT <Sr» CO. 



An Indispensable Work in every Library and Family. 



PRONOUNCING 

Gazetteer of the World. 

OR, 

GEOGRAPHICAL DICTIONARY, 

Comprising over 2300 pages. Giving a Description of nearly One 
Hundred Thousand Places, with a Correct Pronunciation of their 
Names. Revised Edition, with an Appendix, containing nearly 
10,000 New Notices, and the recent Statistical Information, ac- 
cording to the latest Census Returns of the United States and 
Foreign Countries ; the whole being above 30,000 more Geograph- 
ical Notices than are found in any other Gazetteer of the World. 
Edited by J. Thomas, M.D., and T. Baldwin, assisted by several 
other gentlemen. In one Imperial Octavo Volume. Bound in 
Sheep. Price, $10. 



Lippincotf s Pronouncing Gazetteer Co7itains : 

I. — Descriptive Notices of the Countries, Islands, Rivers, Mountains, 
Cities, Towns, etc., in every Part of the Globe, with the most 
Recent and Authentic Information ; 

11. — The Names of all Important Places, etc., both in their Native 
and Foreign Languages, with the PRONUNCIATION of the 
same— a Feature never attempted in any other Work ; 

[II. — The Classical Names of all ancient Places, so far as they can e 
accurately ascertained from the best authorities ; 

IV. — A Complete Etymological Vocabulary of Geographical Names ; 

V. — An Elaborate Introduction, explanatory of the Principles of I ro« 
nunciation of Names in the Danish, Dutch, French, German, 
Greek, Hungarian, Italian, Norwegian, Polish, Portuguese^ 
Russian, Spanish, Swedish and Welsh Languages. 



*^-FOR SALE BY ALL BOOKISELLERS. -®a 



PUBLICATIONS OF J. B, LIPPINC07T 6- CO, 
"A LIBRARY IN ITSELF." 



CHAMBERS^S ENCYCLOPEDIA. 

A Dictionary of Universal Knowledge for the People. Illustrated with 
Numerous Wood Engravings. Complete in Ten Volumes Rovdl 
Octavo. Price per Volume, Cloth, $4.50 ; Sheep, $5 ; Half Turkey, 
$5.50. Accompanied by an Atlas of Forty Maps. Price, Clotli, 
I5 ; Sheep, $5.50; Half Turkey, $6. 

The Publishers have the pleasure of announcing that they have issued 
the concluding PART OF CHAMBERS'S ENCYCLOPAEDIA, and 
that the work is now complete in 

TEN ROYAL OCTAVO VOLUMES, of over 800 pages each, il- 
lustrated with about 4000 engravings, and accom.panied by 

AN ATLAS OF FORTY MAPS ; the whole, it is believed, form- 
ing the most complete work of reference extant. 

The design of this work, as explained in the Notice prefixed to the 
first volume, is that of a Dictionary of Universal Knou^Udge for the 
People — not a mere collection of elaborate treatises in alphabetical 
order, but a work to be readily consulted as a Dictionary on every sub- 
ject on which people generally require some distinct information. Com- 
menced in 1859, the work was brought to a close in 186S, and the 
Editors confidently point to the Ten volumes of which it is composed 
as forming the most Co?n.pre/iensive — as it certainly is the Cheapest — £n- 
cyclopadia ever issued in the English language. 

TO TEACHERS, who are frequently called upon to give succincf 
explanations of topics in the various branches of education, oftei- 
beyond the mere outline of information contained in the text-books, no 
other work will be found so useful ; while the conciseness of the several 
articles has made it practicable to bring the whole work within the 
compass of a few volumes, and to afford it at a small cost compared la 
others of its class. 

FOR THE GENERAL READER. — " Upon its literary merit?," 
says Dr. R. Shelton Mackenzie, " its completeness and accuracy, 
and the extent and variety of its information, there can be only Diie 
opinion. The work is worthy of the high aim and established reputa^ 
tion of its projectors. Art and science, theology and jurisi^^rudencej 
natural history and metaphysics, topography and geography, medicine 
and antiquities, biography and belles-lettres, are all discussed here, not 
in long treatises, but to an extent sufficient to give requisite information 
ai a glance, as it were. Sometimes, when the subject justifies it, more 
minute details are given. ... Its fullness upon American subjects 
ought to recommend it especially in this country, and its low price 
makes it one of the cheapest and most accessible works ever published." 

Copies of the work will he sent to any address in the United States, free of charge 
or receipt of the price hy the Pnhlishers. Liberal Terms to Agetits. 



PUBLICATIONS OF J, B. LIPPINCOTT 6r* CO, 



THE 

Works of Washington Irving. 



EDITIONS OF IRVING'S WORKS. 
A The Knickerbocker Edition. — Large I27n0j on 

superfine laid, tinted paper. Profusely Illustrated with Steel 
Plates and Wood-cuts, elegantly printed from new stereotype 
plates. Complete in 27 vols. Bound in extra cloth, gilt top. 
Per vol. $2.50. Half calf, gilt extra. Per vol. $4. 

//. The Riverside Edition, — \6mo^ on fine white 

paper ; from new stereotype plates. With Steel Plates. Complete 
in 26 vols. Green crape cloth, gilt top, beveled edges. Per voL 
J1.75. Half calf, gilt extra. Per vol. $3.25. 

///. The People's Edition. — From the same stereo- 

type plates as above, but printed on cheaper paper. Complete in 
26 vols. i6mo. With Steel Vignette Titles. Neatly bound in 
cloth. Per vol. $1.25. Half calf neat. Per vol. $2.50. 

IV. The Sunny side Edition. — i2mo^ on fine toned 

paper. With Steel Plates. Complete in 28 vols. Handsomely 
bound in dark-green cloth. Per vol. $2.25. Half calf, gilt extra. 
Per vol. $4. ^^ 

Embracing the following : 



Bracebridge Hall, 
W^olfert's Roost. 
Sketch Book, 
Traveler, 
Knickerbocker, 
Crayon Miscellany, 



Goldsmith, 
A 1 ham bra, 
Columbus, 3 vols., 
Astoria, 
Bfjnneville, 
Mahomet, 2 vols.. 



Granada, 
Salmagundi, 
Spanish Papers, 2 vols. 
Washington, 5 vols., 
Life and Letters, 4 vols. 



The reissue of these works in their several forms is unusually 
elegant. The plates are new, the paper superior, the printing hand 
some, and each, in proportion to price, combining good taste witt 
economy. 



^^KACII WORK SOLD SEPARATELY.-«i 



PUBLICATIONS OF J, B. LIPPIACOTT ^ CO. 

PRESCOTT'S WORKS. 

CROWN OCTAVO EDITION. 

COMPLETE IN FIFTEEN UNIFORM VOLUMES. 

EACH VOLUME WITH PORTRAIT ON STEEL. 

Prcscoifs History of the Reign of Ferdinand and 

Isabella the Catholic. Three vols. 8vo. 
Preseotfs Biographical and Critical Miscellanies. 

With a finely engraved steel Portrait of the Author. One vol. 8vo. 

Preseotfs History of the Conquest of Mexico^ with 

a Prelinn'nary View of the Ancient Mexican Civilization, and the 
Life of the Conqueror, Fernando Cortez. In three vols. 8vo. 

Preseotfs History of the Reign of Philip the 

Second, King of Spain. In three vols. 8vo. 

Preseotfs History of the Conquest of Peru ^ with a 
Preliminary View of the Civilization of the Incas. In two vols. 8vo. 

Preseotfs Robertson's History of the Reign of the 

Emperor Charles the Fifth. With an account of the Emperor's 

Life after his Abdica.tion. In three vols. 8vo. 
Each work sold separately. Price per vol., cloth, ^2.50 ; half calf, 
neat, $3.75 ; half calf, gilt extra, marble edges, $4.25 ; half Turkey, gilt 
top, $4.50. Complete sets, printed on tinted paper, handsomely bound 
in green or claret-colored cloth, gilt top, beveled boards. Price, ^40. 



< « »-o » 



CHAMBERS'S BOOK OF DAYS. 

The Book of Days: A Miscellany of Popular An' 

tiquities in connection with the Calendar, including Anecdote, 
Piography and History, Curiosities of Literature, and Oddities of 
Human Life and Character. In two vols, royal 8vo. Price per 
set, cloth, $g ; sheep, $10 ; half Turkey, $11. Edited under the 
supervision of Robert Chambers. 
This work consists of 

I. — Matters connected with the Church Calendar, including the Popu- 
lar Festivals, Saints' Days, and other Holidays, with illustra* 
tions of Christian Antiquities in general. 
TT. — Phenomena connected with the Seasonal Changes. 
Ill, — Folk-Lore of the United Kingdom : namely, Popular Notions and 

Observances connected with Times and Seasons. 
IV. — Notable Events, Biographies and Anecdotes connected with the 
I )ays of the Year. 
V. — Articles of Popular Archaeology, of an entertaining character 
tending to illustrate the progress of Civilization, Manners, 
Literature and Ideas in those kingdoms. 
VL — Curious, Fugitive and Inedited Pieces. 

The work is printed in a new, elegant and readable type and iUu» 
trated with an abundance of Woor' Engravings. 



rUBLICATIONS OF J. B. LIPPINCOTT 6- CO, 
LIPPINCOTT^S PRONOUNCING DICTIONARY 



OF 

BIOGRAPHY AND MYTHOLOGY 

Containing Memoirs of the Eminent persons of all Ages and Countries 
and Accounts of the Various Subjects of the Norse, Hindoo and 
Classic Mythologies, with the Pronunciation of their Names in 
the different Languages in which they occur. By J. Thomas, 
A. AF., M. D. Imperial 8vo. Published in Parts ( f 64 pages. 
Price 50 cents per Part. In two handsome vols. Per vol., extra 
cloth, $11. Sheep, $12. Half Turkey, $13.50. 
This invaluable work embraces the following peculiar itatures to an 

eminent degree : 

I. GREAT COMPLETENESS AND CONCISENESS IN THE BIOGRAPHICAL 

SKETCHES. 
II. SUCCINCT BUT COMPREHENSIVE ACCOUNTS OF ALL THE MORE INTEREST- 
ING SUBJECTS OF MYTHOLOGY. 
ni. A LOGICAL SYSTEM OF ORTHOGRAPHY. 
IV. THE ACCURATE PRONUNCIATION OF THE NAMES. 
V. FULL BIBLIOGRAPHICAL REFERENCES. 



** I have taken the trouble to look out a 

large miniber of names, such as seen:ed 
to me good tests of the compass, suf- 
ficency and accuracy of the biographical 
notices. The resVit has been in a high 
degree satisfactory. So far as I have ex- 
amined nobody vv.-^s omitted that deserved 
a place, and the just proportions were 
maintained between the various claim- 
ants to their page, or paragraph, or line. 
The star of the first magnitude was riot 
shorn of its radiance, and the scarcely visi- 
ble spark was allowed its little glimmer. ' — 
From Dr. Oi,iver Wendell Holmes. 

" It is a work which I shall be glad to 
possess, both on account of the fullness 
of its matter, and because the pronuncia- 
tion of the names is given. I have had 
occasion, from the other works of Dr. 
Thomas, to be convinced of his great ex- 
actness in that respect. I'he work will be 
a valunble addicion to the books of refer- 
ence in our lanf,uage." — Frovi William 
Cullen Bryant. 



" I can speak in high terms of the tho- 
roughness and accuracy with which the 
work has been prepared. It is a store- 
house of valuable and trustworthy infor- 
mation. I'he pronunciation of the names, 
which is systematically given, will add 
much to the usefulness of the work." — 
From Prof. James Hadley, Yale Col- 
lege. 

" I think that the work when completed 
will supply a real want. I was esjiecially 
pleased with the sensible and learned 
preface of the editor, and am persuaded 
that he has cliosen the tiue system of 
orthograj^hy. From what 1 know of Dr. 
I'homas, 1 feel sure tiiat he will give us a 
book that may be dependea on for com- 
prehensiveness and accurav.y, the two 
great desideranda in such an undertak- 
ing." — Frovi Frof. J as. Ri;ssell Low- 
ell. 

"It is the most x-aluable work of the 
kind in English that I have seen."- -From 
Gen. R. E. Lee, Washington College. 



Special Circulars, containing a full description of the work, with 
specimen p.'ges, will be sent, post-paid, on application. 

Subscript. ons received by the Publishers, and the Parts forwarded to 
subscribers by mail, post-paid, as issued, on receipt of the price (50 
2ents) for each part. 

A [rents wanted in all parts of the United States on liberal terms. 
Address the Publishers. 



K, 6 ^^ : J 






■.'•■.-:'„ 



'.^' •:* re t- '! 



.■Is.'#rl.>j ♦.■'>' 



? 



K^^;. 






■-i'v.^ 



■ v^-- 



.: ./. 



. %*.;•■' 







',^ti^ 



isi,J 



■'. ^: 



'.♦ii.-^' 






i? 



